Healthcare Provider Details

I. General information

NPI: 1073644423
Provider Name (Legal Business Name): CEDAR PARK PEDIATRIC AND FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 04/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 CYPRESS CREEK RD SUITE 104
CEDAR PARK TX
78613-4483
US

IV. Provider business mailing address

345 CYPRESS CREEK RD SUITE 104
CEDAR PARK TX
78613-4483
US

V. Phone/Fax

Practice location:
  • Phone: 512-336-2777
  • Fax:
Mailing address:
  • Phone: 512-336-2777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. BRENT CARDWELL
Title or Position: OFFICE MANAGER
Credential:
Phone: 512-336-2777