Provider Demographics
NPI:1740241777
Name:WATEMBERG, ISAAC AARON (MD)
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:AARON
Last Name:WATEMBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-281-8245
Mailing Address - Fax:817-882-9910
Practice Address - Street 1:1307 8TH AVE STE 106
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4141
Practice Address - Country:US
Practice Address - Phone:817-335-8478
Practice Address - Fax:817-882-9910
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4290207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175798103Medicaid
TX8J9056OtherBCBS