MEDICARE: DR. MARK RICHARD DAMBRO M.D.

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	208D00000X	General Practice Physician	H3998	TX
2	207Q00000X	Family Medicine Physician	H3998	TX

General Provider Information

NPI Number	:	1528061009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK RICHARD DAMBRO M.D.

Provider Business Mailing Address
First Line	:	PO BOX 100685
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76185-0685
Country	:	US
Telephone Number	:	817-233-8781
Fax Number	:

Provider Business Practice Location Address
First Line	:	4450 OAK PARK LN # 100685
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-9538
Country	:	US
Telephone Number	:	817-233-8781
Fax Number	:

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	09/03/2019

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