Basic Information
| Provider Information | |||||||||
| NPI: | 1215602750 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST DALLAS TWO MEDICAL GROUP, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16131 N ELDRIDGE PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | TOMBALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773779130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814298525 | ||||||||
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| Address1: | 16131 N ELDRIDGE PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | TOMBALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773779130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814298525 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2021 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | WELTON | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2814298525 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.