MEDICARE: DR. JOHN ALBERT MENCHACA M.D.

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	208000000X	Pediatrics Physician	D4226	TX

General Provider Information

NPI Number	:	1770522070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN ALBERT MENCHACA M.D.

Provider Business Mailing Address
First Line	:	800 8TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2600
Country	:	US
Telephone Number	:	817-336-7275
Fax Number	:	817-336-8594

Provider Business Practice Location Address
First Line	:	800 8TH AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2601
Country	:	US
Telephone Number	:	817-336-7275
Fax Number	:	817-336-8594

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

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	07/08/2007

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