Provider Demographics
NPI:1295020360
Name:CREEKSIDE DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:CREEKSIDE DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MSO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:
Authorized Official - Last Name:AGUIRRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-407-6856
Mailing Address - Street 1:8900 SHOAL CREEK BLVD BLDG 300B
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8900 SHOAL CREEK BLVD BLDG 300B
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757
Practice Address - Country:US
Practice Address - Phone:512-407-8656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD90432084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXA67522Medicare UPIN