Provider Demographics
NPI:1417944901
Name:GREAT OAKS FAMILY PRACTICE, PA
Entity Type:Organization
Organization Name:GREAT OAKS FAMILY PRACTICE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-246-3338
Mailing Address - Street 1:15930 S GREAT OAKS DR
Mailing Address - Street 2:A-200
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-5526
Mailing Address - Country:US
Mailing Address - Phone:512-246-3338
Mailing Address - Fax:512-246-3368
Practice Address - Street 1:15930 S GREAT OAKS DR
Practice Address - Street 2:A-200
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-5526
Practice Address - Country:US
Practice Address - Phone:512-246-3338
Practice Address - Fax:512-246-3368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1080207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXJ1080OtherSTATE MEDICAL LICENSE
8B8579Medicare ID - Type Unspecified
F51678Medicare UPIN