Healthcare Provider Details

I. General information

NPI: 1508370701
Provider Name (Legal Business Name): PEDS CENTER OF ROUND ROCK PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2017
Last Update Date: 11/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1526 LEANDER RD
GEORGETOWN TX
78628-8801
US

IV. Provider business mailing address

1526 LEANDER RD
GEORGETOWN TX
78628-8801
US

V. Phone/Fax

Practice location:
  • Phone: 512-863-7586
  • Fax: 512-863-5222
Mailing address:
  • Phone: 512-863-7586
  • Fax: 512-863-5222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: VIVEKANANDA DASARI
Title or Position: OWNER
Credential: M.D.
Phone: 201-289-7621