Healthcare Provider Details

I. General information

NPI: 1184849432
Provider Name (Legal Business Name): DIANE FAGELMAN BIRK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12880 HILLCREST RD STE 104
DALLAS TX
75230-6557
US

IV. Provider business mailing address

12880 HILLCREST RD STE 104
DALLAS TX
75230-6557
US

V. Phone/Fax

Practice location:
  • Phone: 972-387-4747
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD5603
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: