Healthcare Provider Details

I. General information

NPI: 1134344625
Provider Name (Legal Business Name): PREVENTIAMED, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 10/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 S CAPITAL OF TEXAS HWY BUILDING III, SUITE 400
WEST LAKE HILLS TX
78746-6446
US

IV. Provider business mailing address

1250 S CAPITAL OF TEXAS HWY BUILDING III, SUITE 400
WEST LAKE HILLS TX
78746-6446
US

V. Phone/Fax

Practice location:
  • Phone: 512-308-6349
  • Fax:
Mailing address:
  • Phone: 512-308-6349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DIETER ROBERT MARTIN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 512-308-6349