Basic Information
| Provider Information | |||||||||
| NPI: | 1780612390 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | M DS CYBER CLINIC PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTHWEST DIAGNOSTIC CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 500 W WHITESTONE BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CEDAR PARK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786132245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122503900 | ||||||||
| FaxNumber: | 5122496232 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W WHITESTONE BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CEDAR PARK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786132245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5122503900 | ||||||||
| FaxNumber: | 5122496232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 01/04/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOGDANOVICH | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | BRUCE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5122503900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | H6779 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 00769N | 01 | TX | MEDICARE PTAN | OTHER |