Provider Demographics
NPI:1598795189
Name:HART, MICHAEL WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:HART
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2360 DEAN WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-1379
Mailing Address - Country:US
Mailing Address - Phone:817-527-3470
Mailing Address - Fax:817-527-3497
Practice Address - Street 1:6006 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-5620
Practice Address - Country:US
Practice Address - Phone:817-984-1026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8187207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111729303Medicaid
TX111729303Medicaid
TX458611Medicare PIN
TX00T01ZMedicare PIN