Healthcare Provider Details

I. General information

NPI: 1184947368
Provider Name (Legal Business Name): STAR STATE HEART, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 03/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 RANCH ROAD 620 S SUITE 201
LAKEWAY TX
78734-5631
US

IV. Provider business mailing address

PO BOX 41239
AUSTIN TX
78704-0021
US

V. Phone/Fax

Practice location:
  • Phone: 512-334-7855
  • Fax: 512-445-6095
Mailing address:
  • Phone: 512-334-7876
  • Fax: 512-445-6095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG6655
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberG6655
License Number StateTX

VIII. Authorized Official

Name: SAMUEL JAMES DEMAIO JR.
Title or Position: SOLE MBR
Credential: M.D.
Phone: 512-709-8229