MEDICARE: KEVIN B. WALDREP, M.D.,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	208600000X	Surgery Physician

General Provider Information

NPI Number	:	1841814506
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEVIN B. WALDREP, M.D.,PLLC

Provider Business Mailing Address
First Line	:	7777 FOREST LN STE B111
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75230-2539
Country	:	US
Telephone Number	:	972-566-4204
Fax Number	:

Provider Business Practice Location Address
First Line	:	7777 FOREST LN STE B111
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75230-2539
Country	:	US
Telephone Number	:	972-566-4204
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIAL/DIRECTOR
Name	:	MR. FRANCISCO A RODRIGUEZ
Credential	:
Telephone Number	:	972-566-4204

Provider Enumeration Date	:	05/28/2020
Last Update Date	:	06/12/2020

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