Healthcare Provider Details

I. General information

NPI: 1700816923
Provider Name (Legal Business Name): CENTRAL TEXAS KIDNEY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 10/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 W 45TH ST
AUSTIN TX
78751-3014
US

IV. Provider business mailing address

408 W 45TH ST
AUSTIN TX
78751-3014
US

V. Phone/Fax

Practice location:
  • Phone: 512-451-5800
  • Fax: 512-451-5800
Mailing address:
  • Phone: 512-451-5800
  • Fax: 512-451-5800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LISA DONNELLY
Title or Position: ADM
Credential: ADM
Phone: 512-451-5800