Healthcare Provider Details

I. General information

NPI: 1083888523
Provider Name (Legal Business Name): TEXAS DIABETES AND ENDOCRINOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2008
Last Update Date: 07/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 DEEPWOOD DR SUITE 104
ROUND ROCK TX
78681-4944
US

IV. Provider business mailing address

6500 NORTH MOPAC BLDG. 3, SUITE 200
AUSTIN TX
78731
US

V. Phone/Fax

Practice location:
  • Phone: 512-458-8400
  • Fax: 512-458-8593
Mailing address:
  • Phone: 512-458-8400
  • Fax: 512-458-8593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number StateTX

VIII. Authorized Official

Name: THOMAS C BLEVINS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 512-458-8400