Healthcare Provider Details

I. General information

NPI: 1083934830
Provider Name (Legal Business Name): AUSTIN FERTILITY INSTITUTE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 06/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 PARK BEND DR BLDG. 2 - SUITE 204
AUSTIN TX
78758-5387
US

IV. Provider business mailing address

2200 PARK BEND DR BLDG. 2 - SUITE 204
AUSTIN TX
78758-5387
US

V. Phone/Fax

Practice location:
  • Phone: 512-339-4234
  • Fax: 512-339-4237
Mailing address:
  • Phone: 512-339-4234
  • Fax: 512-339-4237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License NumberN5874
License Number StateTX

VIII. Authorized Official

Name: DR. KENNETH KAMYAR MOGHADAM
Title or Position: DIRECTOR/PHYSICIAN
Credential: MD
Phone: 512-339-4234