Healthcare Provider Details

I. General information

NPI: 1386713691
Provider Name (Legal Business Name): BURTON J ZUNG PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5658 WESCREEK DR STE 400 STE 400
FORT WORTH TX
76133
US

IV. Provider business mailing address

5658 WESTCREEK DR STE 400
FORT WORTH TX
76133-2254
US

V. Phone/Fax

Practice location:
  • Phone: 972-424-9212
  • Fax: 972-509-1450
Mailing address:
  • Phone: 972-424-9212
  • Fax: 972-509-1450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number21099
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: