Provider Demographics
NPI:1194730242
Name:BLEDSOE, MAYA B (MD)
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:B
Last Name:BLEDSOE
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 1:11111 RESEARCH BLVD #475
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-5283
Practice Address - Country:US
Practice Address - Phone:512-338-8181
Practice Address - Fax:512-338-8375
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4173207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX045997602Medicaid
TX045997601Medicaid
TX045997602Medicaid
TX8K0568Medicare PIN
TX87J405Medicare PIN