Provider Demographics
NPI:1023026341
Name:OBBINK, JOHN W JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:OBBINK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6401 HARRIS PKWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-6101
Mailing Address - Country:US
Mailing Address - Phone:817-346-9111
Mailing Address - Fax:
Practice Address - Street 1:6401 HARRIS PKWY
Practice Address - Street 2:SUITE 120
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-6101
Practice Address - Country:US
Practice Address - Phone:817-346-9111
Practice Address - Fax:817-346-9714
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0149207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX041747902Medicaid
TXTXB117210Medicare PIN
TX275740YKPWMedicare PIN
TXE99562Medicare UPIN
TX041747902Medicaid
TXTXB117211Medicare PIN