Provider Demographics
NPI:1871590471
Name:ABERNETHY, JOAN L (MD)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:L
Last Name:ABERNETHY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:L
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6551 HARRIS PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-6103
Mailing Address - Country:US
Mailing Address - Phone:817-423-1800
Mailing Address - Fax:817-510-0964
Practice Address - Street 1:6551 HARRIS PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-6103
Practice Address - Country:US
Practice Address - Phone:817-423-1800
Practice Address - Fax:817-510-0964
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5322207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170396908Medicaid
TX170396902Medicaid
TX170396903Medicaid
TX170396902Medicaid
TXH56224Medicare UPIN
TX170396903Medicaid
TX170396908Medicaid