Provider Demographics
NPI:1659784627
Name:MABRY-CANTU, CARLYE (MD)
Entity Type:Individual
Prefix:
First Name:CARLYE
Middle Name:
Last Name:MABRY-CANTU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 N MO PAC EXPY.
Mailing Address - Street 2:STE 420
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731
Mailing Address - Country:US
Mailing Address - Phone:512-482-0045
Mailing Address - Fax:512-476-9892
Practice Address - Street 1:7000 N MO PAC EXPY STE 420
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3055
Practice Address - Country:US
Practice Address - Phone:512-482-0045
Practice Address - Fax:512-476-9892
Is Sole Proprietor?:No
Enumeration Date:2014-06-08
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR1817207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine