Basic Information
| Provider Information | |||||||||
| NPI: | 1740258615 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOSTER | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4502 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103584000 | ||||||||
| FaxNumber: | 2105676418 | ||||||||
| Practice Location | |||||||||
| Address1: | 4502 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103584000 | ||||||||
| FaxNumber: | 2105676418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 05/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085P0229X | 46276 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | 46276 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 64863806 | 05 | KY | MEDICAID | 098528 | 01 | KY | SIHO - KCR | OTHER | 200220770 | 05 | IN | MEDICAID | 368706302 | 01 | TX | CSHCN | OTHER | 50020477 | 01 | KY | PASSPORT - KCR | OTHER | 32512200 | 05 | WI | MEDICAID | 368706301 | 05 | TX | MEDICAID |