Healthcare Provider Details

I. General information

NPI: 1184270845
Provider Name (Legal Business Name): SPINE DFW PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 W LBJ FWY STE 465
IRVING TX
75063-3869
US

IV. Provider business mailing address

24 GLEN ABBEY DR
DALLAS TX
75248-2799
US

V. Phone/Fax

Practice location:
  • Phone: 214-680-9881
  • Fax:
Mailing address:
  • Phone: 214-680-9881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NEIL SHAH
Title or Position: OWNER
Credential:
Phone: 214-680-9881