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General NPI Number Information
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NPI Number | 1639267982
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Entity Type | Organization
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Legal Business Name | FOSSIL CREEK FAMILY MEDICAL CENTER
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Dates
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Enumeration Date | 10/11/2006
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Last Update Date | 03/15/2019
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Provider Practice Location Address
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Address Line | 7510 N BEACH ST
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City | FORT WORTH
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State | TX
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Zip | 76137
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Country | US
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Telephone | 817-498-1818
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Fax | 817-581-3761
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Provider Business Mailing Address
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Address Line | 7500 N BEACH ST
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City | FORT WORTH
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State | TX
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Zip | 76137-1505
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Country | US
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Telephone | 817-498-1818
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Fax | 817-581-3761
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Authorized Official
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Title or Position | OWNER
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Name | DAVID WAYNE SIMONAK
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Credential | DO
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Telephone | 817-498-1818
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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