Basic Information
| Provider Information | |||||||||
| NPI: | 1134351950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GO | ||||||||
| FirstName: | JON AVERY | ||||||||
| MiddleName: | TAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GO | ||||||||
| OtherFirstName: | JON AVERY | ||||||||
| OtherMiddleName: | T | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 87 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782910087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103589172 | ||||||||
| FaxNumber: | 2103589183 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 S ZARZAMORA ST | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782075209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103587000 | ||||||||
| FaxNumber: | 2103587406 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2009 | ||||||||
| LastUpdateDate: | 10/26/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD 18347 | HI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | P1643 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.