MEDICARE: KHIDJA SEYMOUR

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	207NS0135X	Procedural Dermatology Physician	KK307596	CA
2	207NS0135X	Procedural Dermatology Physician	KK37596	CA

General Provider Information

NPI Number	:	1548777683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KHIDJA SEYMOUR

Provider Business Mailing Address
First Line	:	2915 JONAH DR APT 118
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76108-5937
Country	:	US
Telephone Number	:	817-917-6181
Fax Number	:

Provider Business Practice Location Address
First Line	:	5288 TRAIL LAKE DR STE 13
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-1939
Country	:	US
Telephone Number	:	817-917-6181
Fax Number	:

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

Provider Enumeration Date	:	01/10/2018
Last Update Date	:	06/16/2018

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Directions to “ KHIDJA SEYMOUR ” Practice Location

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