Basic Information
Provider Information | |||||||||
NPI: | 1083679294 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRAL TEXAS MEDICAL ASSOCIATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2005 MEDICAL PKWY | ||||||||
Address2: | SUITE C | ||||||||
City: | SAN MARCOS | ||||||||
State: | TX | ||||||||
PostalCode: | 786667576 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5127533756 | ||||||||
FaxNumber: | 5123530807 | ||||||||
Practice Location | |||||||||
Address1: | 2005 MEDICAL PKWY | ||||||||
Address2: | SUITE C | ||||||||
City: | SAN MARCOS | ||||||||
State: | TX | ||||||||
PostalCode: | 786667576 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5123963911 | ||||||||
FaxNumber: | 5123530807 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2006 | ||||||||
LastUpdateDate: | 07/11/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ELDRIDGE | ||||||||
AuthorizedOfficialFirstName: | DEBRA | ||||||||
AuthorizedOfficialMiddleName: | GAY | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5123530744 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D0168 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 114603702 | 05 | TX |   | MEDICAID |