Provider Demographics
NPI:1154607604
Name:WIX, KURTT R (DO)
Entity type:Individual
Prefix:DR
First Name:KURTT
Middle Name:R
Last Name:WIX
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2601
Mailing Address - Country:US
Mailing Address - Phone:817-336-2100
Mailing Address - Fax:
Practice Address - Street 1:800 8TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2601
Practice Address - Country:US
Practice Address - Phone:817-336-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-28
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10036690207Q00000X
TXP6552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX307244YUAKMedicare PIN