Healthcare Provider Details

I. General information

NPI: 1215344676
Provider Name (Legal Business Name): NITIKA MIMANI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 08/08/2021
Certification Date: 08/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 W SLAUGHTER LN STE 490
AUSTIN TX
78748-6208
US

IV. Provider business mailing address

4515 SETON CENTER PKWY STE 215
AUSTIN TX
78759-5785
US

V. Phone/Fax

Practice location:
  • Phone: 512-282-8967
  • Fax: 512-406-7351
Mailing address:
  • Phone: 512-338-3826
  • Fax: 512-406-6216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR2018
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: