Provider Demographics
NPI:1407049034
Name:UNIVERSITY FAMILY MEDICAL CLINIC P.A.
Entity Type:Organization
Organization Name:UNIVERSITY FAMILY MEDICAL CLINIC P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:H
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:WILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-338-0555
Mailing Address - Street 1:117 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-1922
Mailing Address - Country:US
Mailing Address - Phone:817-338-0555
Mailing Address - Fax:817-338-4039
Practice Address - Street 1:117 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-1922
Practice Address - Country:US
Practice Address - Phone:817-338-0555
Practice Address - Fax:817-338-4039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0939261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center