Healthcare Provider Details

I. General information

NPI: 1235282112
Provider Name (Legal Business Name): CAPITAL PEDIATRIC GROUP ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 06/30/2014
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: 512-279-0445
Mailing address:
  • Phone: 512-454-4545
  • Fax: 512-279-0445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE0921
License Number StateTX

VIII. Authorized Official

Name: DOROTHY CAROLE CAMPBELL
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 512-454-4545