Provider Demographics
NPI:1295854974
Name:WALLIS, ROBERT RANDOLPH (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:RANDOLPH
Last Name:WALLIS
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 1:547 LUPIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401-5023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:547 LUPIN ST
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-5023
Practice Address - Country:US
Practice Address - Phone:713-665-0852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD9706207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine