Healthcare Provider Details

I. General information

NPI: 1235198706
Provider Name (Legal Business Name): AMY J JATZLAU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 05/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 B EAST RAILROAD
GIDDINGS TX
78942
US

IV. Provider business mailing address

219 B EAST RAILROAD
GIDDINGS TX
78942
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:
Title or Position:
Credential:
Phone: