Provider Demographics
NPI:1548777683
Name:SEYMOUR, KHIDJA
Entity Type:Individual
Prefix:
First Name:KHIDJA
Middle Name:
Last Name:SEYMOUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2915 JONAH DR APT 118
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76108-5937
Mailing Address - Country:US
Mailing Address - Phone:817-917-6181
Mailing Address - Fax:
Practice Address - Street 1:5288 TRAIL LAKE DR STE 13
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-1939
Practice Address - Country:US
Practice Address - Phone:817-917-6181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAKK307596207NS0135X
CAKK37596207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty