Provider Demographics
NPI:1033500475
Name:ROCKWALL NEUROLOGY, PA
Entity Type:Organization
Organization Name:ROCKWALL NEUROLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIO
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-443-0742
Mailing Address - Street 1:7501 LAKEVEIW PARKWAY
Mailing Address - Street 2:SUITE 245
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-9326
Mailing Address - Country:US
Mailing Address - Phone:469-443-0742
Mailing Address - Fax:469-443-0501
Practice Address - Street 1:9330 POPPY DR
Practice Address - Street 2:SUITE 500B
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-4621
Practice Address - Country:US
Practice Address - Phone:469-443-0742
Practice Address - Fax:469-443-0501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP53242084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX294760Medicare PIN