Provider Demographics
NPI:1366570087
Name:CUSTODIO, ISRAEL D (PA-C)
Entity type:Individual
Prefix:MR
First Name:ISRAEL
Middle Name:D
Last Name:CUSTODIO
Suffix:
Gender:M
Credentials:PA-C
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Other - First Name:
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Mailing Address - Street 1:4805 FREDERICKSBURG RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3627
Mailing Address - Country:US
Mailing Address - Phone:210-979-7999
Mailing Address - Fax:210-798-2457
Practice Address - Street 1:4805 FREDERICKSBURG RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3627
Practice Address - Country:US
Practice Address - Phone:210-979-7999
Practice Address - Fax:210-798-2457
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA01549363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical