Provider Demographics
NPI:1558655274
Name:FORT WORTH LUNG CLINIC, PA
Entity Type:Organization
Organization Name:FORT WORTH LUNG CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEREJE
Authorized Official - Middle Name:SAHEL
Authorized Official - Last Name:AYO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-739-1080
Mailing Address - Street 1:PO BOX 16284
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76162-0284
Mailing Address - Country:US
Mailing Address - Phone:817-739-1080
Mailing Address - Fax:817-370-7942
Practice Address - Street 1:11803 SOUTH FWY STE 311
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7036
Practice Address - Country:US
Practice Address - Phone:817-568-8411
Practice Address - Fax:817-568-8414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-31
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0617261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXN0617OtherLICENCE