Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | D9864 | TX |
N | 2080P0208X | Pediatric Infectious Diseases | D9864 | TX |
NPI | 1407810344 |
---|---|
Provider Name | John K Podgore |
First Address | Fort Worth, TX 76199-0335 |
Second Address | Fort Worth, TX 76107-2553 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/04/2006 |
Last Update Date | 16/02/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
125514302 | (05) | TX |
125514303 | CSHCN (01) | TX |
847309 | BCBS (01) | TX |
F50751 | (02) | TX |