Healthcare Provider Details

I. General information

NPI: 1154332054
Provider Name (Legal Business Name): KRISTYN TIFFANY FAGERBERG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KRISTYN TIFFANY HODES M.D.

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11805 FM 2244 RD STE 100
BEE CAVE TX
78738-5337
US

IV. Provider business mailing address

PO BOX 844658
DALLAS TX
75284-4658
US

V. Phone/Fax

Practice location:
  • Phone: 512-402-9013
  • Fax: 512-402-9016
Mailing address:
  • Phone: 254-724-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL3294
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: