Healthcare Provider Details

I. General information

NPI: 1356703243
Provider Name (Legal Business Name): TERESA R KROEKER MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12319 N MOPAC EXPY 260
AUSTIN TX
78758-2414
US

IV. Provider business mailing address

12319 N MOPAC EXPY 260
AUSTIN TX
78758-2414
US

V. Phone/Fax

Practice location:
  • Phone: 512-491-0017
  • Fax: 512-491-0063
Mailing address:
  • Phone: 512-491-0017
  • Fax: 512-491-0063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateTX

VIII. Authorized Official

Name: TERESA R KROEKER
Title or Position: PRESIDENT
Credential: MD
Phone: 512-491-0017