Provider Demographics
NPI:1740369073
Name:WATAUGA FAMILY PRACTICE PA
Entity type:Organization
Organization Name:WATAUGA FAMILY PRACTICE PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:HODGSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-485-0161
Mailing Address - Street 1:5445 BASSWOOD BLVD
Mailing Address - Street 2:SUITE 650
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-4437
Mailing Address - Country:US
Mailing Address - Phone:817-485-0161
Mailing Address - Fax:817-485-9430
Practice Address - Street 1:5445 BASSWOOD BLVD
Practice Address - Street 2:SUITE 650
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-4437
Practice Address - Country:US
Practice Address - Phone:817-485-0161
Practice Address - Fax:817-485-9430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2993207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB23551Medicare UPIN