Healthcare Provider Details

I. General information

NPI: 1134496094
Provider Name (Legal Business Name): MINIMALLY INVASIVE SPINECARE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2011
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 N MACARTHUR BLVD
IRVING TX
75038-6497
US

IV. Provider business mailing address

4301 N MACARTHUR BLVD
IRVING TX
75038-6497
US

V. Phone/Fax

Practice location:
  • Phone: 972-255-5588
  • Fax:
Mailing address:
  • Phone: 972-255-5588
  • Fax: 972-255-6688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberL9018
License Number StateTX

VIII. Authorized Official

Name: DOUGLAS S WON
Title or Position: OWNER
Credential: M.D.
Phone: 972-255-5588