Provider Demographics
NPI:1083888523
Name:TEXAS DIABETES AND ENDOCRINOLOGY PA
Entity Type:Organization
Organization Name:TEXAS DIABETES AND ENDOCRINOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:BLEVINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-458-8400
Mailing Address - Street 1:6500 NORTH MOPAC
Mailing Address - Street 2:BLDG. 3, SUITE 200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731
Mailing Address - Country:US
Mailing Address - Phone:512-458-8400
Mailing Address - Fax:512-458-8593
Practice Address - Street 1:170 DEEPWOOD DR
Practice Address - Street 2:SUITE 104
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4944
Practice Address - Country:US
Practice Address - Phone:512-458-8400
Practice Address - Fax:512-458-8593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207RE0101X, 364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Z148Medicare PIN