Healthcare Provider Details

I. General information

NPI: 1306228432
Provider Name (Legal Business Name): MOLLY M WARTHAN MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 8TH AVE STE 120
FORT WORTH TX
76104-4155
US

IV. Provider business mailing address

1622 8TH AVE STE 120
FORT WORTH TX
76104-4155
US

V. Phone/Fax

Practice location:
  • Phone: 817-923-8220
  • Fax: 817-923-9004
Mailing address:
  • Phone: 817-923-8220
  • Fax: 817-923-9004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberN2335
License Number StateTX

VIII. Authorized Official

Name: DR. MOLLY M WARTHAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 817-923-8220