Provider Demographics
NPI:1386620797
Name:JACQUE ANGERSTEIN, DO, PA
Entity type:Organization
Organization Name:JACQUE ANGERSTEIN, DO, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGERSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-328-3311
Mailing Address - Street 1:3700 LOST CREEK BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-1461
Mailing Address - Country:US
Mailing Address - Phone:512-328-3111
Mailing Address - Fax:512-328-2752
Practice Address - Street 1:2765 BEE CAVES RD STE 201
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-5640
Practice Address - Country:US
Practice Address - Phone:512-328-3311
Practice Address - Fax:512-328-2751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7623207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0058PWOtherBCBS OF TEXAS ID
TX166196901Medicaid
TX166196901Medicaid