Healthcare Provider Details

I. General information

NPI: 1346322625
Provider Name (Legal Business Name): ANDREW H KILGUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 05/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W NORTHWEST HWY STE 900
GRAPEVINE TX
76051-8112
US

IV. Provider business mailing address

PO BOX 99371
FORT WORTH TX
76199-0371
US

V. Phone/Fax

Practice location:
  • Phone: 817-488-7573
  • Fax: 817-488-5096
Mailing address:
  • Phone: 682-885-1855
  • Fax: 682-885-7347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG4326
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: