Provider Demographics
NPI:1811037245
Name:LOVELACE, CANDIS M (MD)
Entity Type:Individual
Prefix:
First Name:CANDIS
Middle Name:M
Last Name:LOVELACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CANDIS
Other - Middle Name:M
Other - Last Name:THACKARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4400 HERITAGE TRACE PARKWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244
Mailing Address - Country:US
Mailing Address - Phone:817-380-1087
Mailing Address - Fax:817-380-1088
Practice Address - Street 1:4400 HERITAGE TRACE PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244
Practice Address - Country:US
Practice Address - Phone:817-380-1087
Practice Address - Fax:817-380-1088
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN38452086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX208491501Medicaid
TX8CC632OtherBCBS
TX208491501Medicaid