Healthcare Provider Details

I. General information

NPI: 1104973171
Provider Name (Legal Business Name): CENTRAL TEXAS PEDIATRIC ENDOCRINOLOGY AND DIABETES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 NORTHLAND DR SUITE 308
AUSTIN TX
78731-4945
US

IV. Provider business mailing address

PO BOX 140494
AUSTIN TX
78714-0494
US

V. Phone/Fax

Practice location:
  • Phone: 512-467-9444
  • Fax: 512-467-9550
Mailing address:
  • Phone: 512-467-9444
  • Fax: 512-467-9550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberG4757
License Number StateTX

VIII. Authorized Official

Name: DR. MARY JANE WRAY
Title or Position: PRESIDENT
Credential: M.D., PHD
Phone: 512-467-9444