Healthcare Provider Details

I. General information

NPI: 1407808652
Provider Name (Legal Business Name): FORT WORTH PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5708 EDWARDS RANCH ROAD
FORT WORTH TX
76109
US

IV. Provider business mailing address

5708 EDWARDS RANCH ROAD
FORT WORTH TX
76109
US

V. Phone/Fax

Practice location:
  • Phone: 817-336-4040
  • Fax: 817-336-6780
Mailing address:
  • Phone: 817-336-4040
  • Fax: 817-336-6780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number StateTX

VIII. Authorized Official

Name: DIANE A RICHEY
Title or Position: BUSINESS ADMINISTRATOR
Credential:
Phone: 817-336-4040