Individual
CHANIDA K SUPAVONG
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
5450 CLEARFORK MAIN ST STE 460, FORT WORTH, TX 76109
(817) 423-5121
(817) 423-5122
Mailing address
5450 CLEARFORK MAIN ST STE 460, FORT WORTH, TX 76109-3560
(817) 423-5121
(817) 423-5122
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
P5896
TX
Other
Enumeration date
05/02/2011
Last updated
07/25/2018
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