Healthcare Provider Details

I. General information

NPI: 1932116902
Provider Name (Legal Business Name): NISHANT B JALANDHARA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 02/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 HERITAGE TRACE PKWY STE 312
FORT WORTH TX
76244-8904
US

IV. Provider business mailing address

1000 W CANNON ST
FORT WORTH TX
76104-3029
US

V. Phone/Fax

Practice location:
  • Phone: 817-877-5858
  • Fax:
Mailing address:
  • Phone: 817-725-7900
  • Fax: 682-207-1030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number0435141
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number15251
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code207RH0005X
TaxonomyHypertension Specialist Physician
License Number0435141
License Number StateKS
# 4
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberQ5824
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: