Healthcare Provider Details

I. General information

NPI: 1508562109
Provider Name (Legal Business Name): MR. AUSTIN ROSS SEKULA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MAIN ST
FORT WORTH TX
76104-4917
US

IV. Provider business mailing address

1500 S MAIN ST
FORT WORTH TX
76104-4917
US

V. Phone/Fax

Practice location:
  • Phone: 817-702-3636
  • Fax:
Mailing address:
  • Phone: 817-702-3636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: