Basic Information
| Provider Information | |||||||||
| NPI: | 1710902473 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVID | ||||||||
| FirstName: | FANG | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 W TERRELL AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178204906 | ||||||||
| FaxNumber: | 8178204815 | ||||||||
| Practice Location | |||||||||
| Address1: | 1300 W TERRELL AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178204906 | ||||||||
| FaxNumber: | 8178204815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 07/12/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | L6854 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 161072705 | 05 | TX | MEDICAID | 8B5307 | 01 | TN | BCBS | OTHER | P00126810 | 01 | TX | RR MEDICARE | OTHER | 161072706 | 05 | TX | MEDICAID | 161072703 | 05 | TX | MEDICAID | 161072702 | 05 | TX | MEDICAID | 161072704 | 05 | TX | MEDICAID |