Provider Demographics
NPI:1073902557
Name:BIRDOW, ANTHONY MICHEAL
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:MICHEAL
Last Name:BIRDOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76112-2384
Mailing Address - Country:US
Mailing Address - Phone:972-598-2002
Mailing Address - Fax:
Practice Address - Street 1:5601 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76112-2384
Practice Address - Country:US
Practice Address - Phone:972-598-2002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34427598172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker