Healthcare Provider Details

I. General information

NPI: 1063638443
Provider Name (Legal Business Name): KELLY G THORSTAD MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12120 RANCH ROAD 620 N
AUSTIN TX
78750-1079
US

IV. Provider business mailing address

12120 RANCH ROAD 620 N
AUSTIN TX
78750-1079
US

V. Phone/Fax

Practice location:
  • Phone: 512-833-7334
  • Fax: 512-833-7333
Mailing address:
  • Phone: 512-833-7334
  • Fax: 512-833-7333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberL0651
License Number StateTX

VIII. Authorized Official

Name: DR. KELLY G THORSTAD
Title or Position: PHYSICIAN OWNER
Credential: MD
Phone: 512-833-7334