Provider Demographics
NPI:1265600639
Name:MONTY V. TRIMBLE , MD, P.A
Entity type:Organization
Organization Name:MONTY V. TRIMBLE , MD, P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:MONTY
Authorized Official - Middle Name:V
Authorized Official - Last Name:TRIMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-377-5223
Mailing Address - Street 1:3455 LOCKE AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-5719
Mailing Address - Country:US
Mailing Address - Phone:817-377-5223
Mailing Address - Fax:817-529-6205
Practice Address - Street 1:3455 LOCKE AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-5719
Practice Address - Country:US
Practice Address - Phone:817-377-5223
Practice Address - Fax:817-529-6205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4150174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXL4150OtherSTATES LICENSE
TX166931901Medicaid
TXL4150OtherSTATES LICENSE