Provider Demographics
NPI:1841436078
Name:SOUTHWEST SURGERY AND WOUND CARE PHYSICIANS
Entity type:Organization
Organization Name:SOUTHWEST SURGERY AND WOUND CARE PHYSICIANS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REZA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOBARAK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:972-424-3505
Mailing Address - Street 1:502 N VALLEY PKWY STE 2
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3437
Mailing Address - Country:US
Mailing Address - Phone:972-316-0902
Mailing Address - Fax:972-316-1161
Practice Address - Street 1:5804 COIT RD STE 100
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75023-5955
Practice Address - Country:US
Practice Address - Phone:972-424-3505
Practice Address - Fax:972-497-2580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
293D00000X
TX1714213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No293D00000XLaboratoriesPhysiological LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A3500Medicare UPIN
TX6237770001Medicare NSC