Provider Demographics
NPI:1366458630
Name:DAGHESTANI, ANAS (MD)
Entity type:Individual
Prefix:
First Name:ANAS
Middle Name:
Last Name:DAGHESTANI
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 1:6210 E HIGHWAY 290 STE 240
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1144
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:6835 AUSTIN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3189
Practice Address - Country:US
Practice Address - Phone:512-388-8470
Practice Address - Fax:512-445-6532
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2021-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1616207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174473202Medicaid
TX174473201Medicaid
TX174473203Medicaid
TXTXB154519Medicare PIN
TX174473201Medicaid
TX8D7576Medicare PIN
TXP01022968Medicare PIN
TX8J9922Medicare PIN