Provider Demographics
NPI:1902218852
Name:PEDERSON, KATHERINE (DO)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6278
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-0278
Mailing Address - Country:US
Mailing Address - Phone:817-568-5467
Mailing Address - Fax:817-568-5474
Practice Address - Street 1:1757 BROAD PARK CIR N STE 201
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-7839
Practice Address - Country:US
Practice Address - Phone:817-806-1130
Practice Address - Fax:817-806-1133
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ7593207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine