Provider Demographics
NPI:1346608536
Name:FORMULA WELLNESS PLLC
Entity Type:Organization
Organization Name:FORMULA WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-931-9443
Mailing Address - Street 1:4342 LOVERS LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-6921
Mailing Address - Country:US
Mailing Address - Phone:214-931-9443
Mailing Address - Fax:214-602-2017
Practice Address - Street 1:4342 LOVERS LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75225-6921
Practice Address - Country:US
Practice Address - Phone:214-931-9443
Practice Address - Fax:214-602-2017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1038207L00000X, 207Q00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX129767308Medicaid