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General NPI Number Information
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NPI Number | 1669665774
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Entity Type | Organization
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Legal Business Name | FORT WORTH DIAGNOSTIC CLINIC PA
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Dates
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Enumeration Date | 08/22/2007
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Last Update Date | 03/17/2015
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Provider Practice Location Address
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Address Line | 1650 W ROSEDALE ST STE 100
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City | FORT WORTH
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State | TX
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Zip | 76104-7400
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Country | US
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Telephone | 817-338-1131
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Fax | 817-877-1511
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Provider Business Mailing Address
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Address Line | 1650 W ROSEDALE ST STE 100
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City | FORT WORTH
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State | TX
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Zip | 76104-7400
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Country | US
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Telephone | 817-338-1131
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Fax | 817-877-1511
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. PAUL JAY GOLDMAN
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Credential | M.D.
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Telephone | 817-338-1131
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | E8262
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License Number State | TX
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