Healthcare Provider Details

I. General information

NPI: 1295130706
Provider Name (Legal Business Name): SANDRA MABEL CAMACHO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SANDRA CAMACHO GOMEZ MD

II. Dates (important events)

Enumeration Date: 10/27/2014
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 BARBARA JORDAN BLVD STE 401
AUSTIN TX
78723-3078
US

IV. Provider business mailing address

1301 BARBARA JORDAN BLVD STE 401
AUSTIN TX
78723-3078
US

V. Phone/Fax

Practice location:
  • Phone: 512-324-5938
  • Fax:
Mailing address:
  • Phone: 512-324-5938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberU8034
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: