=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114022753
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CECILIA MARINA CERVANTES M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2006
-----------------------------------------------------
Last Update Date | 08/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5114 BALCONES WOODS DR SUITE 307-347
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78759-5273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-466-2621
-----------------------------------------------------
Fax | 888-550-6132
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5114 BALCONES WOODS DR STE 307-347
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78759-5273
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-667-4343
-----------------------------------------------------
Fax | 512-249-6119
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083P0011X
-----------------------------------------------------
Taxonomy Name | Undersea and Hyperbaric Medicine (Preventive Medicine) Physician
-----------------------------------------------------
License Number | 26062004
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | J1631
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------