MEDICARE: COLLEYVILLE PHYSICIANS DFW PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician

General Provider Information

NPI Number	:	1043137052
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLEYVILLE PHYSICIANS DFW PLLC

Provider Business Mailing Address
First Line	:	PO BOX 5190
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71171-5190
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1710 HIGHWAY 287 N
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-7630
Country	:	US
Telephone Number	:	855-590-7473
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ANDY DAVIS
Credential	:
Telephone Number	:	205-212-0289

Provider Enumeration Date	:	07/01/2026
Last Update Date	:	07/01/2026

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