1619071362 NPI number — AUSTIN BONE & JOINT CLINIC A PROF A ASSOC

Table of content: AZITA MOGHADDAM DDS (NPI 1063633436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619071362 NPI number — AUSTIN BONE & JOINT CLINIC A PROF A ASSOC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AUSTIN BONE & JOINT CLINIC A PROF A ASSOC
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:
Provider Other Organization Name Type Code:
6
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:
1619071362
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1015 E 32ND ST
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78705-2700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-477-6341
Provider Business Mailing Address Fax Number:
512-477-1148

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1015 E 32ND ST
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78705-2700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-477-6341
Provider Business Practice Location Address Fax Number:
512-477-1148
Provider Enumeration Date:
09/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PEARCE
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ORTHOPEADIC SURGEON
Authorized Official Telephone Number:
512-477-6341

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 081856901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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