=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861679284
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOIRA TERESE DOLAN MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2008
-----------------------------------------------------
Last Update Date | 01/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10201 BRANTLEY BND
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78748-1259
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-350-2898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 849
-----------------------------------------------------
City | MANCHACA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78652-0849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-350-2898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | H7209
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------