Basic Information
| Provider Information | |||||||||
| NPI: | 1740261114 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PICKELL | ||||||||
| FirstName: | STUART | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3455 LOCKE AVE STE 315 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761075747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173361189 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3455 LOCKE AVE STE 315 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761075747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173361189 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 02/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | L2552 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | L2552 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 158677801 | 05 | TX | MEDICAID |