Provider Demographics
NPI:1902005523
Name:SARDAN, MAURICIO A (MD)
Entity Type:Individual
Prefix:
First Name:MAURICIO
Middle Name:A
Last Name:SARDAN
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:PO BOX 26726
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:1301 W. 38TH ST, #205
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1011
Practice Address - Country:US
Practice Address - Phone:512-451-0161
Practice Address - Fax:512-451-8354
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100577207R00000X
TXN7342207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX216320602Medicaid
TX216320603Medicaid
TX216320601Medicaid
TXTXB111340Medicare PIN
TXP00869621Medicare PIN
TXTXB147785Medicare PIN
TXP01161478Medicare PIN
TX216320602Medicaid