Provider Demographics
NPI:1457629503
Name:R LEE ENNIS MD PA
Entity Type:Organization
Organization Name:R LEE ENNIS MD PA
Other - Org Name:RONALD L ENNIS MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:ENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-465-7313
Mailing Address - Street 1:PO BOX 626
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75021-0626
Mailing Address - Country:US
Mailing Address - Phone:903-465-7313
Mailing Address - Fax:903-463-4496
Practice Address - Street 1:2402 W MORTON STE 146
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020
Practice Address - Country:US
Practice Address - Phone:903-465-7313
Practice Address - Fax:903-463-4496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX097089901Medicaid