Basic Information
| Provider Information | |||||||||
| NPI: | 1235226721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE WAAL | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 6300 LA CALMA DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787523843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124528533 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1201 W 38TH ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787051006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123241000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 12/19/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | M5683 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 184866507 | 05 | TX | MEDICAID | 184866501 | 05 | TX | MEDICAID | 8W9493 | 01 | TX | BCBS | OTHER | 8K8349 | 01 | TX | BCBS | OTHER | 8V5765 | 01 | TX | BCBS | OTHER | 184866504 | 05 | TX | MEDICAID | 8S1819 | 01 | TX | BCBS | OTHER | 8X7452 | 01 | TX | BCBS | OTHER | 184866502 | 05 | TX | MEDICAID | 184866503 | 01 | TX | CSHCN | OTHER | 184866505 | 01 | TX | CSHCN | OTHER | 184866506 | 05 | TX | MEDICAID |