MEDICARE: THEODORUS JONATHAN KURKJIAN MD

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	208200000X	Plastic Surgery Physician	264705	NY
2	208200000X	Plastic Surgery Physician	P3374	TX
3	2086S0122X	Plastic and Reconstructive Surgery Physician	P3374	TX

General Provider Information

NPI Number	:	1508066176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THEODORUS JONATHAN KURKJIAN MD

Provider Business Mailing Address
First Line	:	5825 EDWARDS RANCH RD
Second Line	:	STE 200
City	:	FORT WORTH
State	:	TX
Zip	:	76109-4122
Country	:	US
Telephone Number	:	817-870-5080
Fax Number	:	817-870-5064

Provider Business Practice Location Address
First Line	:	800 8TH AVE
Second Line	:	SUITE 336
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2601
Country	:	US
Telephone Number	:	817-870-5080
Fax Number	:	817-870-5064

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2007
Last Update Date	:	08/02/2018

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