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General NPI Number Information
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NPI Number | 1073781050
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Entity Type | Organization
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Legal Business Name | WILLIAM J. VAN WYK M.D., P.A.
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Dates
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Enumeration Date | 02/13/2008
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Last Update Date | 02/16/2011
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Provider Practice Location Address
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Address Line | 803 W TERRELL AVE
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City | FORT WORTH
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State | TX
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Zip | 76104-3155
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Country | US
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Telephone | 817-877-3113
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Fax | 817-877-0022
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Provider Business Mailing Address
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Address Line | 803 W TERRELL AVE
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City | FORT WORTH
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State | TX
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Zip | 76104-3155
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Country | US
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Telephone | 817-877-3113
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Fax | 817-877-0022
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Authorized Official
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Title or Position | PRESIDENT
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Name | WILLIAM J. VAN WYK
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Credential | M.D., P.A.
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Telephone | 817-877-3113
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | D9696
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License Number State | TX
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