Provider Demographics
NPI:1285823526
Name:MALTHESEN, NOLAN SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:NOLAN
Middle Name:SCOTT
Last Name:MALTHESEN
Suffix:
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 1:6311 SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76132-1063
Mailing Address - Country:US
Mailing Address - Phone:817-731-9400
Mailing Address - Fax:817-731-4282
Practice Address - Street 1:6311 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76132-1063
Practice Address - Country:US
Practice Address - Phone:817-731-9400
Practice Address - Fax:817-731-4282
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN8120207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8V9723OtherBCBSTX
TXTXB154995Medicare PIN
TX8V9723OtherBCBSTX