Healthcare Provider Details

I. General information

NPI: 1235450743
Provider Name (Legal Business Name): USMD DIAGNOSTIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date: 09/15/2015
Reactivation Date: 11/17/2016

III. Provider practice location address

1300 W TERRELL AVE SUITE 404
FORT WORTH TX
76104-2820
US

IV. Provider business mailing address

6333 N. STATE HIGHWAY 161, STE 200
IRVING TX
75038-2216
US

V. Phone/Fax

Practice location:
  • Phone: 214-493-4002
  • Fax:
Mailing address:
  • Phone: 214-493-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. CHRIS DUNLEAVY
Title or Position: CFO
Credential:
Phone: 214-493-4000