Healthcare Provider Details

I. General information

NPI: 1518221019
Provider Name (Legal Business Name): POONAM L KAZA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2012
Last Update Date: 07/28/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 7TH AVE
FORT WORTH TX
76104-2733
US

IV. Provider business mailing address

801 7TH AVE
FORT WORTH TX
76104-2733
US

V. Phone/Fax

Practice location:
  • Phone: 682-885-6726
  • Fax:
Mailing address:
  • Phone: 682-885-6726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberU4542
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: