Provider Demographics
NPI:1093378911
Name:JOSEPH, TINA MATHAI
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MATHAI
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6507 S COOPER ST STE 105
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76001-5818
Mailing Address - Country:US
Mailing Address - Phone:817-466-9100
Mailing Address - Fax:817-466-9410
Practice Address - Street 1:6507 S COOPER ST STE 105
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76001-5818
Practice Address - Country:US
Practice Address - Phone:817-466-9100
Practice Address - Fax:817-466-9410
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXT4942207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program