MEDICARE: MEDPEDS MEDICAL CLINIC PA

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	208000000X	Pediatrics Physician
2	207R00000X	Internal Medicine Physician

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00X703	OTHER	TX	MEDICARE GROUP PTAN

General Provider Information

NPI Number	:	1134206139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDPEDS MEDICAL CLINIC PA

Provider Business Mailing Address
First Line	:	4925 CORRIENTE LN
Second Line	:
City	:	BENBROOK
State	:	TX
Zip	:	76126-1853
Country	:	US
Telephone Number	:	817-597-5632
Fax Number	:

Provider Business Practice Location Address
First Line	:	2111 FORT WORTH HWY
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-4834
Country	:	US
Telephone Number	:	817-596-3700
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	DR. NUSRAT A KHAN
Credential	:	MD
Telephone Number	:	817-597-5632

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	11/22/2022

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Directions to “MEDPEDS MEDICAL CLINIC PA ” Practice Location

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