1386899029 NPI number — CENTRAL TEXAS INFECTIOUS DISEASE PA

Table of content: (NPI 1386899029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386899029 NPI number — CENTRAL TEXAS INFECTIOUS DISEASE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL TEXAS INFECTIOUS DISEASE PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHAMALEE N WEERATUNGE
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386899029
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1090
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANCHACA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78652-1090
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-771-9147
Provider Business Mailing Address Fax Number:
512-828-7984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
598 N UNION AVE
Provider Second Line Business Practice Location Address:
STE.350
Provider Business Practice Location Address City Name:
NEW BRAUNFELS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78130-4136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-625-5103
Provider Business Practice Location Address Fax Number:
512-828-7984
Provider Enumeration Date:
11/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WEERATUNGE
Authorized Official First Name:
CHAMALEE
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
210-771-9147

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  M3110 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: M3110 . This is a "TX LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00356308 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 182468201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0093NS . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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