Healthcare Provider Details

I. General information

NPI: 1669469235
Provider Name (Legal Business Name): MARY S MAXWELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 01/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4107 MEDICAL PKWY STE 210
AUSTIN TX
78756-3738
US

IV. Provider business mailing address

4107 MEDICAL PKWY #210
AUSTIN TX
78756-3735
US

V. Phone/Fax

Practice location:
  • Phone: 512-451-4488
  • Fax: 512-453-2707
Mailing address:
  • Phone: 512-451-4488
  • Fax: 512-453-2707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberH0613
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: