Provider Demographics
NPI:1003873845
Name:ROUSE, WILDON MELLINGER III
Entity Type:Individual
Prefix:MR
First Name:WILDON
Middle Name:MELLINGER
Last Name:ROUSE
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1253 N VON MINDEN ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:TX
Mailing Address - Zip Code:78945-1262
Mailing Address - Country:US
Mailing Address - Phone:979-968-8493
Mailing Address - Fax:979-968-6388
Practice Address - Street 1:1253 N VON MINDEN ST
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:TX
Practice Address - Zip Code:78945-1262
Practice Address - Country:US
Practice Address - Phone:979-968-8493
Practice Address - Fax:979-968-6388
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02598363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMDF1715TXOtherWORKERS COMPENSATION
TX308464202Medicaid
TX875N33OtherBC/BS #
TXP00477542OtherRAILROAD MEDICARE
TXP00477542OtherRAILROAD MEDICARE
TX875N33OtherBC/BS #