Healthcare Provider Details

I. General information

NPI: 1740525203
Provider Name (Legal Business Name): RICARDO GUIROLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 COOPER ST
FORT WORTH TX
76104-2710
US

IV. Provider business mailing address

PO BOX 733784
DALLAS TX
75373-3784
US

V. Phone/Fax

Practice location:
  • Phone: 682-885-1202
  • Fax: 682-885-1204
Mailing address:
  • Phone: 682-885-1855
  • Fax: 682-885-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberP6403
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License NumberP6403
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: