Basic Information
| Provider Information | |||||||||
| NPI: | 1467778944 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HABERMAN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | DAVIS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173210300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3500 GASTON AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148202361 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2010 | ||||||||
| LastUpdateDate: | 07/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | Q7381 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.