Individual
MARY BETH MADONNA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
333 N SANTA ROSA, SAN ANTONIO, TX 78207-3108
(210) 704-4100
Mailing address
333 N SANTA ROSA, SAN ANTONIO, TX 78207-3108
(210) 704-4100
Taxonomy
Speciality
Code
Description
License number
State
2086S0120X
Pediatric Surgery Physician
036-083049
IL
2086S0120X
Pediatric Surgery Physician
Primary
U0254
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036083049
—
IL
01
—
1627123
BCBS PROVIDER ID
IL
Enumeration date
09/16/2005
Last updated
11/16/2022
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