MEDICARE: AYESHA KANWAL DO PLLC

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	207RR0500X	Rheumatology Physician	Q2313	TX

General Provider Information

NPI Number	:	1659806511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AYESHA KANWAL DO PLLC

Provider Business Mailing Address
First Line	:	4819 RIVEROAKS BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76114-4656
Country	:	US
Telephone Number	:	817-626-9744
Fax Number	:	817-626-9962

Provider Business Practice Location Address
First Line	:	4819 RIVEROAKS BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76114-3098
Country	:	US
Telephone Number	:	817-626-9744
Fax Number	:	817-626-9962

Authorized Official
Title or Position	:	AUTHORIZED/OWNER
Name	:	DR. AYESHA KANWAL
Credential	:	DO
Telephone Number	:	817-703-8671

Provider Enumeration Date	:	04/27/2017
Last Update Date	:	10/11/2018

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