Healthcare Provider Details

I. General information

NPI: 1700228392
Provider Name (Legal Business Name): UNDRAL ORGIL D.P.M
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 W ROSEDALE ST STE 204
FORT WORTH TX
76104
US

IV. Provider business mailing address

1650 W ROSEDALE ST STE 204
FORT WORTH TX
76104-7400
US

V. Phone/Fax

Practice location:
  • Phone: 178-887-9884
  • Fax:
Mailing address:
  • Phone: 817-887-9884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2339
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: