Healthcare Provider Details

I. General information

NPI: 1083654438
Provider Name (Legal Business Name): FIDELIS KANAYO UNINI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 04/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 HEMPHILL ST. SUITE 101
FORT WORTH TX
76104-4137
US

IV. Provider business mailing address

609 HEMPHILL ST. SUITE 101
FORT WORTH TX
76104-4137
US

V. Phone/Fax

Practice location:
  • Phone: 817-923-8484
  • Fax: 817-923-8494
Mailing address:
  • Phone: 817-923-8484
  • Fax: 817-923-8494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number239922
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM5959
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: