MEDICARE: DIABETES & ENDOCRINE ASSOCIATES OF TARRANT COUNTY, L.L.P.

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	207RE0101X	Endocrinology, Diabetes & Metabolism 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	:	1851305460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIABETES & ENDOCRINE ASSOCIATES OF TARRANT COUNTY, L.L.P.

Provider Business Mailing Address
First Line	:	2000 COOPER ST STE 120
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2535
Country	:	US
Telephone Number	:	817-820-2890
Fax Number	:	817-810-0725

Provider Business Practice Location Address
First Line	:	2000 COOPER ST STE 120
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-2535
Country	:	US
Telephone Number	:	817-820-2890
Fax Number	:	817-810-0725

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	ASHLEY MOLIDOR
Credential	:
Telephone Number	:	817-820-2897

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	02/07/2020

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