Provider Demographics
NPI:1164418364
Name:GULLEDGE, WILLIAM RALPH JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RALPH
Last Name:GULLEDGE
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84767-0247
Mailing Address - Country:US
Mailing Address - Phone:817-929-1815
Mailing Address - Fax:866-221-9981
Practice Address - Street 1:2548 ANASAZI WAY
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:UT
Practice Address - Zip Code:84767
Practice Address - Country:US
Practice Address - Phone:817-921-4191
Practice Address - Fax:866-221-1446
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE92132084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPO84931FGMedicaid
TXB23191Medicare UPIN
TXTXB149356Medicare Oscar/Certification