Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | S6447 | TX |
Y | 111NI0900X | Internist | S6447 | TX |
NPI | 1003347964 |
---|---|
Provider Name | Gabrielle Mavelian |
First Address | Fort Worth, TX 76109-3514 |
Second Address | Fort Worth, TX 76109-3514 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/03/2017 |
Last Update Date | 02/12/2020 |