Provider Demographics
NPI:1043331812
Name:IBERIA MEDICAL CLINIC, P.A.
Entity type:Organization
Organization Name:IBERIA MEDICAL CLINIC, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:E
Authorized Official - Last Name:THOMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-744-7524
Mailing Address - Street 1:546 W SEMINARY DR STE A
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-1361
Mailing Address - Country:US
Mailing Address - Phone:817-924-7978
Mailing Address - Fax:
Practice Address - Street 1:546 W SEMINARY DR STE A
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-1361
Practice Address - Country:US
Practice Address - Phone:817-924-7978
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4172611-01Medicaid
TX4172611-02Medicaid