Healthcare Provider Details

I. General information

NPI: 1588198808
Provider Name (Legal Business Name): CAPITOL GASTRO, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12701 RR 620 N STE 101
AUSTIN TX
78750-1141
US

IV. Provider business mailing address

12701 RR 620 N STE 101
AUSTIN TX
78750-1141
US

V. Phone/Fax

Practice location:
  • Phone: 512-593-6022
  • Fax: 512-599-9130
Mailing address:
  • Phone: 512-593-6022
  • Fax: 512-599-9130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: MASI KHAJA
Title or Position: OWNER
Credential: MD
Phone: 830-637-7761