Provider Demographics
NPI:1811228851
Name:DFW FAMILY CLINIC
Entity Type:Organization
Organization Name:DFW FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ADILA
Authorized Official - Middle Name:NIGHAT
Authorized Official - Last Name:SIDDIQI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-647-0550
Mailing Address - Street 1:2771 SHERMAN ST
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-6016
Mailing Address - Country:US
Mailing Address - Phone:972-647-0550
Mailing Address - Fax:972-647-1010
Practice Address - Street 1:2771 SHERMAN ST
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-6016
Practice Address - Country:US
Practice Address - Phone:972-647-0550
Practice Address - Fax:972-647-1010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-14
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7396207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0076ECOtherBLUE CROSS BLUE SHIELD OF TEXAS
OA5881OtherMEDICARE GROUP PTAN #
TX121398502Medicaid
TX121398502Medicaid