Provider Demographics
NPI:1417317769
Name:INFINITY INVICTUS, PLLC.
Entity Type:Organization
Organization Name:INFINITY INVICTUS, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:WOLTHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-846-8502
Mailing Address - Street 1:12134 JACKSON CREEK DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-5001
Mailing Address - Country:US
Mailing Address - Phone:817-846-8502
Mailing Address - Fax:
Practice Address - Street 1:800 8TH AVE
Practice Address - Street 2:SUITE 326
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2601
Practice Address - Country:US
Practice Address - Phone:972-795-3529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN8596207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1992016869OtherNPI