Healthcare Provider Details

I. General information

NPI: 1366977449
Provider Name (Legal Business Name): USMD DIAGNOSTIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 05/20/2022
Certification Date: 05/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5450 CLEARFORK MAIN ST SUITE 110
FORT WORTH TX
76109-3559
US

IV. Provider business mailing address

5450 CLEARFORK MAIN ST SUITE 110
FORT WORTH TX
76109-3559
US

V. Phone/Fax

Practice location:
  • Phone: 817-505-0222
  • Fax: 817-510-3690
Mailing address:
  • Phone: 817-505-0222
  • Fax: 817-510-3690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD COLEMAN JOHNSTON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: M.D.
Phone: 214-493-4015