MEDICARE: KIDDO PSYCHIATRY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician
2	2084P0804X	Child & Adolescent Psychiatry Physician

General Provider Information

NPI Number	:	1619722444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDDO PSYCHIATRY LLC

Provider Business Mailing Address
First Line	:	11900 JOLLYVILLE RD # 201392
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78759-2304
Country	:	US
Telephone Number	:	512-348-4322
Fax Number	:

Provider Business Practice Location Address
First Line	:	12591 RESEARCH BLVD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78759-2248
Country	:	US
Telephone Number	:	512-348-4322
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	AZKA BILAL
Credential	:
Telephone Number	:	512-348-4322

Provider Enumeration Date	:	04/23/2024
Last Update Date	:	10/22/2024

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