Basic Information
| Provider Information | |||||||||
| NPI: | 1740241777 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATEMBERG | ||||||||
| FirstName: | ISAAC | ||||||||
| MiddleName: | AARON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 961205 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761611205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172818245 | ||||||||
| FaxNumber: | 8178829910 | ||||||||
| Practice Location | |||||||||
| Address1: | 1307 8TH AVE STE 106 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173358478 | ||||||||
| FaxNumber: | 8178829910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 12/08/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | K4290 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 175798103 | 05 | TX | MEDICAID | 8J9056 | 01 | TX | BCBS | OTHER |