Provider Demographics
NPI:1982808556
Name:MACIBORSKI, MELISSA A (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:MACIBORSKI
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: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:512-421-4489
Practice Address - Street 1:151 EXCHANGE BLVD
Practice Address - Street 2:#500
Practice Address - City:HUTTO
Practice Address - State:TX
Practice Address - Zip Code:78634-5381
Practice Address - Country:US
Practice Address - Phone:512-846-1244
Practice Address - Fax:512-846-1963
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP1-0023816208000000X
TXN0237208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
3805159070OtherMYUTMB 3805159070-COMMERCIAL NUMBER
TX195862101Medicaid
TX195862102Medicaid
TX8L1621Medicare PIN
TX8L1273Medicare PIN