Provider Demographics
NPI:1588630578
Name:WALLER, PHILIP A (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:A
Last Name:WALLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:11003 RESOURCE PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77089-6142
Mailing Address - Country:US
Mailing Address - Phone:281-481-8557
Mailing Address - Fax:281-484-7916
Practice Address - Street 1:11003 RESOURCE PKWY STE 102
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-6142
Practice Address - Country:US
Practice Address - Phone:281-481-8557
Practice Address - Fax:281-484-7916
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3933207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5214420001OtherDME
TX8AW783OtherBCBS
TXP00063802OtherRRMC
TXF63759Medicare UPIN
TXP00063802OtherRRMC
TX8B2789Medicare ID - Type Unspecified