Provider Demographics
NPI:1568454304
Name:WISIACKAS, PHILIP ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:ROBERT
Last Name:WISIACKAS
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 1:110 HILL AVE
Mailing Address - Street 2:
Mailing Address - City:COLDSPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77331-5406
Mailing Address - Country:US
Mailing Address - Phone:936-653-4223
Mailing Address - Fax:936-653-5042
Practice Address - Street 1:110 HILL AVE
Practice Address - Street 2:
Practice Address - City:COLDSPRING
Practice Address - State:TX
Practice Address - Zip Code:77331-5406
Practice Address - Country:US
Practice Address - Phone:936-653-4223
Practice Address - Fax:936-653-5042
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00FS32OtherBLUE CROSS BLUE SHIELD
TX133086201Medicaid
TXE28279Medicare UPIN
TX00FS32Medicare ID - Type Unspecified