Healthcare Provider Details

I. General information

NPI: 1982808556
Provider Name (Legal Business Name): MELISSA A MACIBORSKI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 01/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 EXCHANGE BLVD #500
HUTTO TX
78634-5381
US

IV. Provider business mailing address

PO BOX 26726
AUSTIN TX
78755-0726
US

V. Phone/Fax

Practice location:
  • Phone: 512-846-1244
  • Fax: 512-846-1963
Mailing address:
  • Phone: 512-407-8686
  • Fax: 512-421-4489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP1-0023816
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN0237
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: