Healthcare Provider Details

I. General information

NPI: 1790122562
Provider Name (Legal Business Name): JENCY VATHIKULAM D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

763 E US HIGHWAY 80 STE 240
FORNEY TX
75126-8677
US

IV. Provider business mailing address

763 E US HIGHWAY 80 STE 240
FORNEY TX
75126-8677
US

V. Phone/Fax

Practice location:
  • Phone: 469-800-3870
  • Fax:
Mailing address:
  • Phone: 469-800-3870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberQ7977
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: