Healthcare Provider Details

I. General information

NPI: 1346221116
Provider Name (Legal Business Name): JOSE L IGLESIAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
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: 682-885-7080
  • Fax: 682-885-7085
Mailing address:
  • Phone: 682-885-6163
  • Fax: 682-885-7347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberJ4231
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: