Healthcare Provider Details

I. General information

NPI: 1225060155
Provider Name (Legal Business Name): JAMES M BOTHWELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651 W ROSEDALE ST STE 100
FORT WORTH TX
76104-7437
US

IV. Provider business mailing address

1651 W ROSEDALE ST STE 100
FORT WORTH TX
76104-7437
US

V. Phone/Fax

Practice location:
  • Phone: 817-930-2030
  • Fax: 817-930-2031
Mailing address:
  • Phone: 817-930-2030
  • Fax: 817-930-2031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberL4870
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberL4870
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: