Healthcare Provider Details

I. General information

NPI: 1245598408
Provider Name (Legal Business Name): AUTUMN SAVAGE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2012
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W ROSEDALE ST STE A
FORT WORTH TX
76104-2824
US

IV. Provider business mailing address

PO BOX 3409
PFLUGERVILLE TX
78691-3409
US

V. Phone/Fax

Practice location:
  • Phone: 817-730-5300
  • Fax: 817-989-6819
Mailing address:
  • Phone: 513-252-7792
  • Fax: 513-904-5908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberQ2848
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: