MEDICARE: DR. KIM-BINH THI MAI 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	207W00000X	Ophthalmology Physician	Q4189	TX
2	207WX0107X	Retina Specialist (Ophthalmology) Physician	Q4189	TX

General Provider Information

NPI Number	:	1538450721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIM-BINH THI MAI MD

Provider Business Mailing Address
First Line	:	3824 N TARRANT PKWY STE 310
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5431
Country	:	US
Telephone Number	:	817-617-7678
Fax Number	:	817-617-7681

Provider Business Practice Location Address
First Line	:	3824 N TARRANT PKWY STE 310
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5431
Country	:	US
Telephone Number	:	817-617-7678
Fax Number	:	817-617-7681

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

Provider Enumeration Date	:	04/22/2011
Last Update Date	:	07/27/2020

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