Provider Demographics
NPI:1962881441
Name:DFW FAMILY CLINIC
Entity type:Organization
Organization Name:DFW FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ADILA
Authorized Official - Middle Name:N
Authorized Official - Last Name:SIDDIQI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-647-0550
Mailing Address - Street 1:2771 SHERMAN ST
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-6016
Mailing Address - Country:US
Mailing Address - Phone:972-647-0550
Mailing Address - Fax:
Practice Address - Street 1:2771 SHERMAN ST
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-6016
Practice Address - Country:US
Practice Address - Phone:972-647-0550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09381363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA09381OtherPHYSICIAN ASSISTANT PERMIT