Provider Demographics
NPI:1124009543
Name:ROMAN, ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:ROMAN
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 1:110 W SANDY LAKE RD
Mailing Address - Street 2:#102 PMB 105
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-2015
Mailing Address - Country:US
Mailing Address - Phone:214-363-2953
Mailing Address - Fax:214-363-2899
Practice Address - Street 1:6116 N CENTRAL EXPY
Practice Address - Street 2:SUITE 915
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-5162
Practice Address - Country:US
Practice Address - Phone:214-363-2953
Practice Address - Fax:214-363-2899
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ72862084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX043901014Medicaid
TX1750562237OtherGROUP NPI
TX8C6525Medicare PIN
TX043901014Medicaid