Healthcare Provider Details

I. General information

NPI: 1053426601
Provider Name (Legal Business Name): KENNETH LYNN JAMES DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 11/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1712 PENNSYLVANIA AVE
FORT WORTH TX
76104
US

IV. Provider business mailing address

1712 PENNSYLVANIA AVE
FORT WORTH TX
76104
US

V. Phone/Fax

Practice location:
  • Phone: 817-877-5781
  • Fax: 817-877-5782
Mailing address:
  • Phone: 817-877-5781
  • Fax: 817-877-5782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1022
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: