Healthcare Provider Details

I. General information

NPI: 1083620363
Provider Name (Legal Business Name): SUSAN CALLAWAY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 12/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3828 S 1ST ST
AUSTIN TX
78704-7048
US

IV. Provider business mailing address

PO BOX 26726
AUSTIN TX
78755-0726
US

V. Phone/Fax

Practice location:
  • Phone: 512-443-1311
  • Fax: 512-445-6457
Mailing address:
  • Phone: 512-407-8686
  • Fax: 512-421-4489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberE6269
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: