Provider Demographics
NPI:1144586744
Name:CAMMACK, KATHLEEN ELISE (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ELISE
Last Name:CAMMACK
Suffix:
Gender:F
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:P.O. BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:817-378-3699
Practice Address - Street 1:1250 8TH AVE STE 440
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4144
Practice Address - Country:US
Practice Address - Phone:817-502-8484
Practice Address - Fax:817-212-7019
Is Sole Proprietor?:No
Enumeration Date:2012-04-09
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ7156207V00000X
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX358904601Medicaid