=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659366219
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANETTE GRULLON-MEJIA MD.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2005
-----------------------------------------------------
Last Update Date | 04/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | J STREET BUILDING 3000
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-782-4352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | J STREET BUILDING 3000
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-782-4352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | N2097
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------