Provider Demographics
NPI:1164688081
Name:AMY J .JATZLAU, M.D., P.A.
Entity Type:Organization
Organization Name:AMY J .JATZLAU, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:JOANNE
Authorized Official - Last Name:JATZLAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-542-0710
Mailing Address - Street 1:189 S MANSE AVE
Mailing Address - Street 2:
Mailing Address - City:GIDDINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78942-3433
Mailing Address - Country:US
Mailing Address - Phone:979-542-0710
Mailing Address - Fax:979-542-0748
Practice Address - Street 1:189 S MANSE AVE
Practice Address - Street 2:
Practice Address - City:GIDDINGS
Practice Address - State:TX
Practice Address - Zip Code:78942-3433
Practice Address - Country:US
Practice Address - Phone:979-542-0710
Practice Address - Fax:979-542-0748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8576208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168179301Medicaid