Organization
FORT WORTH LUNG CLINIC, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DEREJE SAHEL AYO MD (PRESIDENT)
(817) 739-1080
Entity
Organization
Contact information
Practice address
11803 SOUTH FWY STE 136, BURLESON, TX 76028-8460
(817) 568-8411
(817) 568-8414
Mailing address
PO BOX 16284, FORT WORTH, TX 76162-0284
(817) 739-1080
(817) 370-7942
Taxonomy
Speciality
Code
Description
License number
State
261QP2300X
Primary Care Clinic/Center
Primary
N0617
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
N0617
LICENCE
TX
Enumeration date
05/31/2011
Last updated
02/19/2025
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