1447702964 NPI number — WEST FORT WORTH DERMATOLOGY, P.A.

Table of content: (NPI 1447702964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447702964 NPI number — WEST FORT WORTH DERMATOLOGY, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST FORT WORTH DERMATOLOGY, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447702964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4840 BRYANT IRVIN CT
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76107-7679
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-989-0300
Provider Business Mailing Address Fax Number:
817-377-0970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4840 BRYANT IRVIN CT
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76107-7679
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-989-0300
Provider Business Practice Location Address Fax Number:
817-377-0970
Provider Enumeration Date:
11/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MORRIS
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
FURNISS
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
817-713-4301

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  H7639 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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