Provider Demographics
NPI:1720023963
Name:ABDO, ELLIS NICK III (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:NICK
Last Name:ABDO
Suffix:III
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 1:5701 BRYANT IRVIN RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4029
Mailing Address - Country:US
Mailing Address - Phone:817-346-4200
Mailing Address - Fax:817-361-5031
Practice Address - Street 1:5701 BRYANT IRVIN RD
Practice Address - Street 2:SUITE 302
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4029
Practice Address - Country:US
Practice Address - Phone:817-346-4200
Practice Address - Fax:817-361-5031
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD1279207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX097532803Medicaid
TX8706B1OtherBCBS
TX080180168Medicare PIN
TX8706B1OtherBCBS
C12568Medicare UPIN