Provider Demographics
NPI:1588964662
Name:WATERLOO MED CO
Entity type:Organization
Organization Name:WATERLOO MED CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODLOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-767-2074
Mailing Address - Street 1:6800 W GATE BLVD
Mailing Address - Street 2:STE 132-309
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-4883
Mailing Address - Country:US
Mailing Address - Phone:512-767-2074
Mailing Address - Fax:
Practice Address - Street 1:6800 W GATE BLVD
Practice Address - Street 2:STE 132-309
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-4883
Practice Address - Country:US
Practice Address - Phone:512-767-2074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-23
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5965207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty