Provider Demographics
NPI:1942500913
Name:CAROLYN W. QUIST, DO, PA
Entity Type:Organization
Organization Name:CAROLYN W. QUIST, DO, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:W
Authorized Official - Last Name:QUIST
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-926-1313
Mailing Address - Street 1:1425 8TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4137
Mailing Address - Country:US
Mailing Address - Phone:817-926-1313
Mailing Address - Fax:817-926-7434
Practice Address - Street 1:1425 8TH AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4137
Practice Address - Country:US
Practice Address - Phone:817-926-1313
Practice Address - Fax:817-926-7434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-25
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2705207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1649272972OtherMEDICARE NPI
TX1255093-05Medicaid
TX1255093-05Medicaid
E81492Medicare UPIN