Healthcare Provider Details

I. General information

NPI: 1164688081
Provider Name (Legal Business Name): AMY J .JATZLAU, M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 07/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 S MANSE AVE
GIDDINGS TX
78942-3433
US

IV. Provider business mailing address

189 S MANSE AVE
GIDDINGS TX
78942-3433
US

V. Phone/Fax

Practice location:
  • Phone: 979-542-0710
  • Fax: 979-542-0748
Mailing address:
  • Phone: 979-542-0710
  • Fax: 979-542-0748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberL8576
License Number StateTX

VIII. Authorized Official

Name: DR. AMY JOANNE JATZLAU
Title or Position: MEDICAL DOCTOR
Credential: M.D.
Phone: 979-542-0710