Provider Demographics
NPI:1780971549
Name:UROLOGY CLINICS OF NORTH TEXAS, PLLC
Entity type:Organization
Organization Name:UROLOGY CLINICS OF NORTH TEXAS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JERRI
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-691-1902
Mailing Address - Street 1:1650 REPUBLIC PKWY STE 150
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6917
Mailing Address - Country:US
Mailing Address - Phone:214-692-8262
Mailing Address - Fax:214-696-4190
Practice Address - Street 1:1631 LANCASTER DR STE 350
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3599
Practice Address - Country:US
Practice Address - Phone:214-915-8502
Practice Address - Fax:682-223-5006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-30
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1780971549Medicaid
TX119844209Medicaid