Provider Demographics
NPI:1851591648
Name:MCINTYRE, JOHN BRADLEY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BRADLEY
Last Name:MCINTYRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:P.O. 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:817-740-8450
Mailing Address - Fax:
Practice Address - Street 1:5751 EDWARDS RANCH ROAD, SUITE 200
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109
Practice Address - Country:US
Practice Address - Phone:817-332-8848
Practice Address - Fax:817-335-2670
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN6489207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB155651Medicare PIN