Provider Demographics
NPI:1730572611
Name:CARDIOMETABOLIC CLINIC & RESEARCH CENTER
Entity type:Organization
Organization Name:CARDIOMETABOLIC CLINIC & RESEARCH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:VASUDEVAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:RAGHAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MBBS, MD, MRCP(UK)
Authorized Official - Phone:512-568-6635
Mailing Address - Street 1:115 SUNDANCE PKWY
Mailing Address - Street 2:SUITE 424
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-7914
Mailing Address - Country:US
Mailing Address - Phone:512-568-6635
Mailing Address - Fax:509-694-1312
Practice Address - Street 1:11620 MEDALLION LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-2630
Practice Address - Country:US
Practice Address - Phone:512-297-2611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-16
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2490261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2707726Medicaid
TX2707726Medicaid