Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207K00000X | Allergist & Immunologist | D6743 | TX |
NPI | 1114987013 |
---|---|
Provider Name | Robert Fenton |
First Address | Fort Worth, TX 76104-1017 |
Second Address | Fort Worth, TX 76104-1017 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/03/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B87762 | (02) |