1740369073 NPI number — WATAUGA FAMILY PRACTICE PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740369073 NPI number — WATAUGA FAMILY PRACTICE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WATAUGA FAMILY PRACTICE PA
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:
NORTH TARRANT FAMILY PRACTICE
Provider Other Organization Name Type Code:
3
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:
1740369073
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5445 BASSWOOD BLVD
Provider Second Line Business Mailing Address:
SUITE 650
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76137-4437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-485-0161
Provider Business Mailing Address Fax Number:
817-485-9430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5445 BASSWOOD BLVD
Provider Second Line Business Practice Location Address:
SUITE 650
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76137-4437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-485-0161
Provider Business Practice Location Address Fax Number:
817-485-9430
Provider Enumeration Date:
11/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HODGSON
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
ALLAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
817-485-0161

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  G2993 , 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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