Provider Demographics
NPI:1134206139
Name:MEDPEDS MEDICAL CLINIC PA
Entity type:Organization
Organization Name:MEDPEDS MEDICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NUSRAT
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-597-5632
Mailing Address - Street 1:4925 CORRIENTE LN
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76126-1853
Mailing Address - Country:US
Mailing Address - Phone:817-597-5632
Mailing Address - Fax:
Practice Address - Street 1:2111 FORT WORTH HWY
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-4834
Practice Address - Country:US
Practice Address - Phone:817-596-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00X703OtherMEDICARE GROUP PTAN
TX00X703OtherMEDICARE GROUP PTAN