Healthcare Provider Details

I. General information

NPI: 1760628820
Provider Name (Legal Business Name): ELIZABETH KNACKMUHS REVERE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH MARY KNACKMUHS MD

II. Dates (important events)

Enumeration Date: 12/19/2008
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5339 N IH 35
AUSTIN TX
78723-2557
US

IV. Provider business mailing address

1111 E CESAR CHAVEZ ST
AUSTIN TX
78702-4209
US

V. Phone/Fax

Practice location:
  • Phone: 512-978-8130
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number250049
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number250049
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberR9673
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: