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General NPI Number Information
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NPI Number | 1134206139
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Entity Type | Organization
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Legal Business Name | MEDPEDS MEDICAL CLINIC PA
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 11/22/2022
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Provider Practice Location Address
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Address Line | 2111 FORT WORTH HWY
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City | WEATHERFORD
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State | TX
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Zip | 76086-4834
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Country | US
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Telephone | 817-596-3700
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Fax |
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Provider Business Mailing Address
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Address Line | 4925 CORRIENTE LN
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City | BENBROOK
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State | TX
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Zip | 76126-1853
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Country | US
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Telephone | 817-597-5632
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | DR. NUSRAT A KHAN
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Credential | MD
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Telephone | 817-597-5632
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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