Healthcare Provider Details

I. General information

NPI: 1699132381
Provider Name (Legal Business Name): STEPHEN'S PEDI & PULMONARY PRACTICE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2016
Last Update Date: 02/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 JEROME ST 102
FORT WORTH TX
76104-3945
US

IV. Provider business mailing address

209 W 2ND ST UNIT 201
FORT WORTH TX
76102-3021
US

V. Phone/Fax

Practice location:
  • Phone: 682-231-0207
  • Fax: 817-922-0805
Mailing address:
  • Phone: 682-231-0207
  • Fax: 817-922-0805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PATRICK SOBANDE
Title or Position: CEO
Credential:
Phone: 682-231-0207