MEDICARE: FOUNDATION FAMILY PRACTICE 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	261Q00000X	Clinic/Center
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1699516914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUNDATION FAMILY PRACTICE PLLC

Provider Business Mailing Address
First Line	:	3120 CAPITAL WAY UNIT 602
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-4305
Country	:	US
Telephone Number	:	817-704-3345
Fax Number	:	817-704-3463

Provider Business Practice Location Address
First Line	:	3120 CAPITAL WAY UNIT 602
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76177-4305
Country	:	US
Telephone Number	:	714-704-3345
Fax Number	:	714-704-3463

Authorized Official
Title or Position	:	CEO
Name	:	OLADOTUN OLUSHOLA AKINMURELE
Credential	:	MD
Telephone Number	:	817-704-3345

Provider Enumeration Date	:	06/03/2024
Last Update Date	:	12/06/2024

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Directions to “FOUNDATION FAMILY PRACTICE PLLC ” Practice Location

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