Healthcare Provider Details

I. General information

NPI: 1720010184
Provider Name (Legal Business Name): CAPITAL CARDIOTHORACIC SURGEONS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2217 PARK BEND DR STE 220
AUSTIN TX
78758-5674
US

IV. Provider business mailing address

2217 PARK BEND DR STE 220
AUSTIN TX
78758-5674
US

V. Phone/Fax

Practice location:
  • Phone: 512-494-9985
  • Fax: 512-494-9986
Mailing address:
  • Phone: 512-494-9985
  • Fax: 512-494-9986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. SANDRA EZELL
Title or Position: ADMINISTRATOR
Credential:
Phone: 512-494-9985