Healthcare Provider Details

I. General information

NPI: 1912379322
Provider Name (Legal Business Name): SHAUN KRETZSCHMAR DO PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2015
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 N FM 1187
ALEDO TX
76008-4200
US

IV. Provider business mailing address

317 N FM 1187
ALEDO TX
76008-4200
US

V. Phone/Fax

Practice location:
  • Phone: 817-441-7181
  • Fax: 817-441-7893
Mailing address:
  • Phone: 817-441-7181
  • Fax: 817-441-7893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJ1940
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJ9140
License Number StateTX

VIII. Authorized Official

Name: DR. SHAUN HARDING KRETZSCHMAR
Title or Position: OWNER/PHYSICIAN
Credential: D.O.
Phone: 817-614-6878