Healthcare Provider Details

I. General information

NPI: 1659711000
Provider Name (Legal Business Name): MAXWELL A COATS CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2013
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6404 PAYTON DR
FORT WORTH TX
76131-1209
US

IV. Provider business mailing address

PO BOX 938
ROWLETT TX
75030-0938
US

V. Phone/Fax

Practice location:
  • Phone: 214-227-2457
  • Fax: 214-764-0880
Mailing address:
  • Phone: 214-227-2457
  • Fax: 214-764-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number140545
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: