Healthcare Provider Details

I. General information

NPI: 1194730242
Provider Name (Legal Business Name): MAYA B BLEDSOE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 11/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11111 RESEARCH BLVD #475
AUSTIN TX
78759-5283
US

IV. Provider business mailing address

PO BOX 26726
AUSTIN TX
78755-0726
US

V. Phone/Fax

Practice location:
  • Phone: 512-338-8181
  • Fax: 512-338-8375
Mailing address:
  • Phone: 512-407-8686
  • Fax: 512-421-4489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberH4173
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberH4173
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: