Healthcare Provider Details

I. General information

NPI: 1750483707
Provider Name (Legal Business Name): MARY CHRIS PETROPOULOS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11673 JOLLYVILLE RD SUITE 104
AUSTIN TX
78759
US

IV. Provider business mailing address

11673 JOLLYVILLE RD SUITE 104
AUSTIN TX
78759
US

V. Phone/Fax

Practice location:
  • Phone: 512-338-5130
  • Fax: 512-338-5112
Mailing address:
  • Phone: 512-338-5130
  • Fax: 512-338-5112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberK2096
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: