Healthcare Provider Details

I. General information

NPI: 1558555706
Provider Name (Legal Business Name): AUSTIN DIAGNOSTIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 08/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12221 MOPAC EXPRESSWAY NORTH
AUSTIN TX
78758-2483
US

IV. Provider business mailing address

12221 MOPAC EXPRESSWAY NORTH
AUSTIN TX
78758-2483
US

V. Phone/Fax

Practice location:
  • Phone: 512-901-4937
  • Fax: 512-901-3945
Mailing address:
  • Phone: 512-901-4937
  • Fax: 512-901-3945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. KENDRA ANDERSON
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 512-901-4937