Provider Demographics
NPI:1720167653
Name:PODGURECKI, DAVID NICK (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:NICK
Last Name:PODGURECKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:4110 FLOWER GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76016-3919
Mailing Address - Country:US
Mailing Address - Phone:817-561-4885
Mailing Address - Fax:817-516-7224
Practice Address - Street 1:1670 E BROAD ST
Practice Address - Street 2:SUITE 102
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-1862
Practice Address - Country:US
Practice Address - Phone:817-473-2228
Practice Address - Fax:817-473-4461
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXF3290207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG16922Medicare UPIN