Healthcare Provider Details

I. General information

NPI: 1982845343
Provider Name (Legal Business Name): ALEX NELSON AUTRY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2009
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MAIN ST
FORT WORTH TX
76104-4917
US

IV. Provider business mailing address

PO BOX 732973
DALLAS TX
75391-2973
US

V. Phone/Fax

Practice location:
  • Phone: 817-702-3431
  • Fax:
Mailing address:
  • Phone: 817-702-3431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number51401
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberN9502
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number51401
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: