Healthcare Provider Details

I. General information

NPI: 1063823474
Provider Name (Legal Business Name): IAN PATTERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W 39TH 1/2 ST
AUSTIN TX
78756-3902
US

IV. Provider business mailing address

1100 W 39TH 1/2 ST
AUSTIN TX
78756-3902
US

V. Phone/Fax

Practice location:
  • Phone: 512-454-4545
  • Fax: 888-653-3677
Mailing address:
  • Phone: 475-355-4711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR3177
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: