Healthcare Provider Details

I. General information

NPI: 1659535177
Provider Name (Legal Business Name): EAST AUSTIN OBGYN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14900 AVERY RANCH BLVD C200-54
AUSTIN TX
78717-3951
US

IV. Provider business mailing address

14900 AVERY RANCH BLVD C200-54
AUSTIN TX
78717-3951
US

V. Phone/Fax

Practice location:
  • Phone: 512-784-2543
  • Fax:
Mailing address:
  • Phone: 512-784-2543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberG7522
License Number StateTX

VIII. Authorized Official

Name: ARTHUR JAMES GORE
Title or Position: DIRECTOR
Credential: M.D.
Phone: 512-784-2543