Provider Demographics
NPI:1669665774
Name:FORT WORTH DIAGNOSTIC CLINIC PA
Entity Type:Organization
Organization Name:FORT WORTH DIAGNOSTIC CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-338-1131
Mailing Address - Street 1:1650 W ROSEDALE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7400
Mailing Address - Country:US
Mailing Address - Phone:817-338-1131
Mailing Address - Fax:817-877-1511
Practice Address - Street 1:1650 W ROSEDALE ST STE 100
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7400
Practice Address - Country:US
Practice Address - Phone:817-338-1131
Practice Address - Fax:817-877-1511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8262174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX083588601Medicaid
TX87T873Medicare PIN
TX083588601Medicaid