Provider Demographics
NPI:1043257686
Name:EWALT, DAVID H (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:H
Last Name:EWALT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:4001 W 15TH ST STE 300
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5802
Practice Address - Country:US
Practice Address - Phone:214-750-0808
Practice Address - Fax:682-303-9572
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG93452088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134977106Medicaid
TX119844204OtherMEDICAID SPECIAL PROGRAMS
TX134977109Medicaid
80419XOtherBCBS PROVIDER ID
TX134977108OtherMEDICAID CSN
TX134977108OtherMEDICAID CSN
TX8D9644Medicare PIN
80419XOtherBCBS PROVIDER ID