Provider Demographics
NPI:1326377730
Name:VISWAJYOTHI MAMBAPOOR, MD, PA
Entity Type:Organization
Organization Name:VISWAJYOTHI MAMBAPOOR, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VISWAJYOTHI
Authorized Official - Middle Name:
Authorized Official - Last Name:MAMBAPOOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-251-7007
Mailing Address - Street 1:200 N HEATHERWILDE BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-3530
Mailing Address - Country:US
Mailing Address - Phone:512-251-7007
Mailing Address - Fax:512-251-4442
Practice Address - Street 1:200 N HEATHERWILDE BLVD STE B
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-3530
Practice Address - Country:US
Practice Address - Phone:512-251-7007
Practice Address - Fax:512-251-4442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1124207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00662QOtherMEDICARE PTAN
TX146610401Medicaid
TX146610401Medicaid