Provider Demographics
NPI:1992753818
Name:AMPELAS, MICHAEL CHARLES (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:AMPELAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:900 W MAGNOLIA AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-8517
Mailing Address - Country:US
Mailing Address - Phone:817-921-6166
Mailing Address - Fax:817-921-9594
Practice Address - Street 1:900 W MAGNOLIA AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-8517
Practice Address - Country:US
Practice Address - Phone:817-921-6166
Practice Address - Fax:817-921-9594
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8265207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX167450904Medicaid
TXP00271501Medicare PIN
TX8D6375Medicare PIN
TXI16891Medicare UPIN