Provider Demographics
NPI:1982100087
Name:PUCYLOWSKI, AUSTIN JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:JEFFREY
Last Name:PUCYLOWSKI
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 1:16207 RED CEDAR TRL
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-3939
Mailing Address - Country:US
Mailing Address - Phone:414-651-3192
Mailing Address - Fax:
Practice Address - Street 1:12222 MERIT DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-2217
Practice Address - Country:US
Practice Address - Phone:888-339-8727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT3364207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty