Healthcare Provider Details

I. General information

NPI: 1447229224
Provider Name (Legal Business Name): JILL A GRAMER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6312 AZLE AVE # 200
FORT WORTH TX
76135-2442
US

IV. Provider business mailing address

6312 AZLE AVE STE 200
LAKE WORTH TX
76135-2442
US

V. Phone/Fax

Practice location:
  • Phone: 682-841-1056
  • Fax: 682-841-1161
Mailing address:
  • Phone: 682-841-1056
  • Fax: 682-841-1161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberK3212
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: