Basic Information
| Provider Information | |||||||||
| NPI: | 1093711012 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALZEL | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3705 MEDICAL PKWY STE 250 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787051022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123021210 | ||||||||
| FaxNumber: | 5124519752 | ||||||||
| Practice Location | |||||||||
| Address1: | 3705 MEDICAL PKWY STE 250 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787051022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123021210 | ||||||||
| FaxNumber: | 5124519752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2005 | ||||||||
| LastUpdateDate: | 02/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | G8490 | TX | Y | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.