1790154102 NPI number — FORT WORTH INFECTIOUS DISEASE CONSULTANTS PLLC

Table of content: (NPI 1790154102)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790154102 NPI number — FORT WORTH INFECTIOUS DISEASE CONSULTANTS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORT WORTH INFECTIOUS DISEASE CONSULTANTS PLLC
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:
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Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790154102
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11803 SOUTH FWY STE 111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLESON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76028-7028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-349-9500
Provider Business Mailing Address Fax Number:
817-349-9501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11803 SOUTH FWY STE 111
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLESON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76028-7028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-349-9500
Provider Business Practice Location Address Fax Number:
817-349-9501
Provider Enumeration Date:
09/16/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BOBBILI
Authorized Official First Name:
KRISHNA
Authorized Official Middle Name:
KANTH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
704-877-4690

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  N5578 , 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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