MEDICARE: ANGELA DONNA SELF MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	L5900	TX

General Provider Information

NPI Number	:	1346230547
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA DONNA SELF MD

Provider Business Mailing Address
First Line	:	3500 NOBLE AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111-4618
Country	:	US
Telephone Number	:	817-632-6000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3500 NOBLE AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111-4618
Country	:	US
Telephone Number	:	817-632-6000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2005
Last Update Date	:	09/27/2021

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