Healthcare Provider Details

I. General information

NPI: 1710776927
Provider Name (Legal Business Name): JACOB WARETI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 05/05/2025
Certification Date: 05/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 MUELLER BLVD STE 3J.018
AUSTIN TX
78723-3051
US

IV. Provider business mailing address

8030 MARILYN RD
REYNOLDSBURG OH
43068-3730
US

V. Phone/Fax

Practice location:
  • Phone: 512-324-0067
  • Fax:
Mailing address:
  • Phone: 614-557-6349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP10093770
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: