Healthcare Provider Details

I. General information

NPI: 1972609162
Provider Name (Legal Business Name): VISWAJYOTHI MAMBAPOOR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 METROPOLIS DR
AUSTIN TX
78744-3111
US

IV. Provider business mailing address

7901 METROPOLIS DR
AUSTIN TX
78744-3111
US

V. Phone/Fax

Practice location:
  • Phone: 512-823-4000
  • Fax:
Mailing address:
  • Phone: 512-823-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL1124
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberL1124
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: