Healthcare Provider Details

I. General information

NPI: 1306803937
Provider Name (Legal Business Name): VINCENT M. TJIA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 W BEN WHITE BLVD
AUSTIN TX
78704-7035
US

IV. Provider business mailing address

408 W 45TH ST
AUSTIN TX
78751-3014
US

V. Phone/Fax

Practice location:
  • Phone: 512-320-1500
  • Fax: 512-459-1399
Mailing address:
  • Phone: 512-320-1500
  • Fax: 512-459-1399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberL5587
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: