MEDICARE: LAKE COUNTRY FAMILY MEDICINE, P.A.

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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629392063
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE COUNTRY FAMILY MEDICINE, P.A.

Provider Business Mailing Address
First Line	:	8465 BOAT CLUB RD STE 115
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-3676
Country	:	US
Telephone Number	:	817-260-0535
Fax Number	:	817-984-1448

Provider Business Practice Location Address
First Line	:	8465 BOAT CLUB RD STE 115
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-3676
Country	:	US
Telephone Number	:	817-260-0535
Fax Number	:	817-984-1448

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	YUNG CHEN
Credential	:	DO
Telephone Number	:	817-260-0535

Provider Enumeration Date	:	03/14/2010
Last Update Date	:	03/12/2026

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