Healthcare Provider Details

I. General information

NPI: 1891053245
Provider Name (Legal Business Name): MELANIE H LAGOMICHOS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2012
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 8TH AVE STE 403
FORT WORTH TX
76104-4143
US

IV. Provider business mailing address

855 MONTGOMERY ST
FORT WORTH TX
76107-2553
US

V. Phone/Fax

Practice location:
  • Phone: 682-207-1375
  • Fax: 682-207-1377
Mailing address:
  • Phone: 817-725-7900
  • Fax: 682-207-1030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberQ8280
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: