Provider Demographics
NPI:1952328551
Name:BRISCOE, JOHN G (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:BRISCOE
Suffix:
Gender:M
Credentials:MD
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 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:817-740-8400
Mailing Address - Fax:817-433-5100
Practice Address - Street 1:6100 HARRIS PARKWAY
Practice Address - Street 2:SUITE 355
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4134
Practice Address - Country:US
Practice Address - Phone:817-433-5488
Practice Address - Fax:817-433-5125
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0210207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114118604Medicaid
TX110246615OtherRAIL ROAD MEDICARE