Provider Demographics
NPI:1730257429
Name:WILFORD HALL USAF MEDICAL CENTER
Entity type:Organization
Organization Name:WILFORD HALL USAF MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARLON
Authorized Official - Middle Name:B
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-292-6707
Mailing Address - Street 1:116 TRILLIUM LN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-2513
Mailing Address - Country:US
Mailing Address - Phone:210-342-6789
Mailing Address - Fax:
Practice Address - Street 1:2200 BERGQUIST DR
Practice Address - Street 2:
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-9907
Practice Address - Country:US
Practice Address - Phone:210-292-7361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2298302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00D862Medicare ID - Type Unspecified
TXD66635Medicare UPIN