Healthcare Provider Details

I. General information

NPI: 1437101136
Provider Name (Legal Business Name): CHRISTOPHER M. MCGONNELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 FOREST LN STE B300
DALLAS TX
75230-2571
US

IV. Provider business mailing address

P.O. BOX 961205
FORT WORTH TX
76161-1205
US

V. Phone/Fax

Practice location:
  • Phone: 972-284-7770
  • Fax: 972-284-7780
Mailing address:
  • Phone: 817-740-8450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM3320
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: