Provider Demographics
NPI:1104858380
Name:DISRAELI, PHILLIP H (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:H
Last Name:DISRAELI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 FM 544 STE 200
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75056-4915
Mailing Address - Country:US
Mailing Address - Phone:469-800-4250
Mailing Address - Fax:469-800-4260
Practice Address - Street 1:1700 FM 544 STE 200
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75056-4915
Practice Address - Country:US
Practice Address - Phone:469-800-4250
Practice Address - Fax:469-800-4260
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5904207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX106132703Medicaid
89336JMedicare ID - Type Unspecified
A95044Medicare UPIN
TX106132703Medicaid
TXTXB154539Medicare PIN