Healthcare Provider Details

I. General information

NPI: 1316077761
Provider Name (Legal Business Name): GARY VICTOR BARTHOLOMEW D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5450 CLEARFORK MAIN ST STE 220
FORT WORTH TX
76109-3562
US

IV. Provider business mailing address

5450 CLEARFORK MAIN ST STE 410
FORT WORTH TX
76109-3559
US

V. Phone/Fax

Practice location:
  • Phone: 817-505-0233
  • Fax: 817-332-3172
Mailing address:
  • Phone: 817-505-0233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number926
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: