Provider Demographics
NPI:1780627919
Name:BAUER, MIRIAM CANTU (MD)
Entity type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:CANTU
Last Name:BAUER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MIRIAM
Other - Middle Name:
Other - Last Name:CANTU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:333 N SANTA ROSA ST
Mailing Address - Street 2:SUITE D4023
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3108
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-2609
Practice Address - Street 1:1434 E SONTERRA BLVD STE 105
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4972
Practice Address - Country:US
Practice Address - Phone:210-479-3000
Practice Address - Fax:210-479-3016
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2410208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111761604Medicaid
TX1265475891OtherGROUP NPI
TX111761605Medicaid
TX173321401Medicaid
TXG48118Medicare UPIN