Provider Demographics
NPI:1538175443
Name:PACKARD, MARSHALL BRANDON (MD)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:BRANDON
Last Name:PACKARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11844 BANDERA RD
Mailing Address - Street 2:PMB 452
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-4132
Mailing Address - Country:US
Mailing Address - Phone:210-223-1145
Mailing Address - Fax:210-615-7619
Practice Address - Street 1:414 NAVARRO ST STE 502
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-2580
Practice Address - Country:US
Practice Address - Phone:210-223-1145
Practice Address - Fax:210-615-7619
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1419207R00000X, 2083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
529251ZWH7OtherMEDICARE PTAN
TX8EE324OtherBCBS ID
TX148874414Medicaid
8CA932OtherBLUE CROSS BLUE SHIELD