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General NPI Number Information
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NPI Number | 1790976934
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Entity Type | Organization
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Legal Business Name | NORTH COUNTRY FAMILY PRACTICE, PA
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Dates
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Enumeration Date | 08/05/2007
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Last Update Date | 02/17/2010
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Provider Practice Location Address
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Address Line | 1050 E. HWY. 114 SUITE 100
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City | SOUTHLAKE
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State | TX
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Zip | 76092-5242
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Country | US
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Telephone | 817-329-8364
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Fax | 817-329-1285
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Provider Business Mailing Address
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Address Line | 1050 E. HWY. 114 SUITE 100
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City | SOUTHLAKE
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State | TX
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Zip | 76092-5242
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Country | US
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Telephone | 817-329-8364
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Fax | 817-329-1285
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | MICHAEL W DOTTI
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Credential | M.D.
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Telephone | 817-329-8364
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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 | TX
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