Provider Demographics
NPI: | 1366458630 |
---|---|
Name: | DAGHESTANI, ANAS (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | ANAS |
Middle Name: | |
Last Name: | DAGHESTANI |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 6210 E HIGHWAY 290 STE 240 |
Mailing Address - Street 2: | |
Mailing Address - City: | AUSTIN |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 78723-1144 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 512-407-8686 |
Mailing Address - Fax: | 512-406-6216 |
Practice Address - Street 1: | 6835 AUSTIN CENTER BLVD |
Practice Address - Street 2: | |
Practice Address - City: | AUSTIN |
Practice Address - State: | TX |
Practice Address - Zip Code: | 78731-3189 |
Practice Address - Country: | US |
Practice Address - Phone: | 512-388-8470 |
Practice Address - Fax: | 512-445-6532 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-31 |
Last Update Date: | 2021-05-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | M1616 | 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 174473202 | Medicaid | |
TX | 174473201 | Medicaid | |
TX | 174473203 | Medicaid | |
TX | TXB154519 | Medicare PIN | |
TX | 174473201 | Medicaid | |
TX | 8D7576 | Medicare PIN | |
TX | P01022968 | Medicare PIN | |
TX | 8J9922 | Medicare PIN |