Healthcare Provider Details

I. General information

NPI: 1720065709
Provider Name (Legal Business Name): BRENT S CARDWELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 CYPRESS CREEK RD STE 104
CEDAR PARK TX
78613-4406
US

IV. Provider business mailing address

PO BOX 15690 DEPT 923
BELFAST ME
04915-4051
US

V. Phone/Fax

Practice location:
  • Phone: 512-336-2777
  • Fax: 512-336-2778
Mailing address:
  • Phone: 512-336-2777
  • Fax: 512-336-2778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberL2169
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: