Healthcare Provider Details

I. General information

NPI: 1184246019
Provider Name (Legal Business Name): CECIL JORDAN STAPLES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 ONION CREEK PKWY
AUSTIN TX
78747-1609
US

IV. Provider business mailing address

2201 ONION CREEK PKWY
AUSTIN TX
78747-1609
US

V. Phone/Fax

Practice location:
  • Phone: 512-649-3376
  • Fax: 512-572-5192
Mailing address:
  • Phone: 512-649-3378
  • Fax: 512-572-5192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberV0549
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: