Provider Demographics
NPI:1578765848
Name:DAVALOS, FERNANDO JR (MD)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:DAVALOS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4340 N JOSEY LN
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4602
Mailing Address - Country:US
Mailing Address - Phone:469-800-4900
Mailing Address - Fax:469-800-4909
Practice Address - Street 1:4340 N JOSEY LN
Practice Address - Street 2:SUITE 204
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4602
Practice Address - Country:US
Practice Address - Phone:469-800-4900
Practice Address - Fax:469-800-4909
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7932207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198099701Medicaid
TX198099703Medicaid
TX8K9807Medicare PIN
TX198099701Medicaid