Provider Demographics
NPI:1235222464
Name:WALTRIP, TRAVIS (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:WALTRIP
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 1:3141 HOOD ST
Mailing Address - Street 2:STE 610
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-5021
Mailing Address - Country:US
Mailing Address - Phone:214-521-6495
Mailing Address - Fax:214-521-6483
Practice Address - Street 1:3141 HOOD ST
Practice Address - Street 2:STE 610
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-5021
Practice Address - Country:US
Practice Address - Phone:214-521-6495
Practice Address - Fax:214-521-6483
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD84712084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
B27415Medicare UPIN
TX00N326Medicare ID - Type Unspecified