Provider Demographics
NPI:1275590796
Name:UNTALAN, RAYMUND M (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMUND
Middle Name:M
Last Name:UNTALAN
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 1:3555 KNICKERBOCKER RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-7610
Mailing Address - Country:US
Mailing Address - Phone:325-949-9555
Mailing Address - Fax:
Practice Address - Street 1:3555 KNICKERBOCKER RD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-7610
Practice Address - Country:US
Practice Address - Phone:325-224-5283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5019207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
86000GOtherBLUE CROSS/BLUE SHIELD TX
TX042392301Medicaid
TX042392301Medicaid
86000GOtherBLUE CROSS/BLUE SHIELD TX