Basic Information
| Provider Information | |||||||||
| NPI: | 1881644474 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FIERKE | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 816 W CANNON ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173210312 | ||||||||
| FaxNumber: | 8173177033 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173210312 | ||||||||
| FaxNumber: | 8173177033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 01/27/2014 | ||||||||
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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 | 2085B0100X | E5750 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | E5750 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | E5750 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | E5750 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0202X | E5750 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | E5750 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | E5750 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | E5750 | 01 | TX | TX PHYSICIANS PERMIT | OTHER | 132546605 | 05 | TX | MEDICAID |