Healthcare Provider Details

I. General information

NPI: 1871677203
Provider Name (Legal Business Name): FORT WORTH FOOT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4759 B SOUTH FREEWAY
FORT WORTH TX
76115
US

IV. Provider business mailing address

4759 B SOUTH FREEWAY
FT WORTH TX
76115
US

V. Phone/Fax

Practice location:
  • Phone: 817-923-1953
  • Fax: 817-923-9615
Mailing address:
  • Phone: 817-923-1953
  • Fax: 817-923-9615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberTX1254
License Number StateTX

VIII. Authorized Official

Name: DR. VICKIE VIJAY KHANNA
Title or Position: DIRECTOR
Credential: DPM
Phone: 817-923-1953