Provider Demographics
NPI:1881847861
Name:DFW INTERNAL MEDICINE CLINIC, PLLC
Entity Type:Organization
Organization Name:DFW INTERNAL MEDICINE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETUA
Authorized Official - Middle Name:
Authorized Official - Last Name:OKOLO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-465-7400
Mailing Address - Street 1:2207 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-5916
Mailing Address - Country:US
Mailing Address - Phone:817-465-7400
Mailing Address - Fax:817-704-7057
Practice Address - Street 1:2207 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76013-5916
Practice Address - Country:US
Practice Address - Phone:817-465-7400
Practice Address - Fax:817-704-7057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0846207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI36396Medicare UPIN