Provider Demographics
NPI:1528176062
Name:CANCER CARE NETWORK OF SOUTH TEXAS PA
Entity type:Organization
Organization Name:CANCER CARE NETWORK OF SOUTH TEXAS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:H
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-545-6972
Mailing Address - Street 1:1200 BROOKLYN AVE
Mailing Address - Street 2:SUITE#115
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-4803
Mailing Address - Country:US
Mailing Address - Phone:210-242-6531
Mailing Address - Fax:210-226-0402
Practice Address - Street 1:1200 BROOKLYN AVE
Practice Address - Street 2:SUITE#115
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-4803
Practice Address - Country:US
Practice Address - Phone:210-242-6531
Practice Address - Fax:210-226-0402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX109514302Medicaid
TX00U40QOtherBLURCROSS/BLUESHIELD TX
TX00U40QOtherBLURCROSS/BLUESHIELD TX
TX109514302Medicaid
TX00U40QMedicare ID - Type Unspecified