Organization
FORT WORTH PEDIATRICS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DIANE RICHEY (ADMINISTRATOR)
(817) 336-4040
Entity
Organization
Contact information
Practice address
1108 S HENDERSON ST, FORT WORTH, TX 76104-4430
(817) 335-3255
(817) 338-9563
Mailing address
1108 S HENDERSON ST, FORT WORTH, TX 76104-4430
(817) 335-3255
(817) 338-9563
Taxonomy
Speciality
Code
Description
License number
State
2080A0000X
Pediatric Adolescent Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
130900703
—
TX
Enumeration date
02/02/2010
Last updated
02/02/2010
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