Provider Demographics
NPI:1609802750
Name:PHALEN, LETITIA EILEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:LETITIA
Middle Name:EILEEN
Last Name:PHALEN
Suffix:
Gender:F
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:PO BOX 13442
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78711-3442
Mailing Address - Country:US
Mailing Address - Phone:512-323-5465
Mailing Address - Fax:
Practice Address - Street 1:5656 BEE CAVES RD. BLDG C STE. 102
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746
Practice Address - Country:US
Practice Address - Phone:512-323-5465
Practice Address - Fax:512-327-1390
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1277207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1029957-02Medicaid
TX102995702Medicaid
TX86324FMedicare ID - Type Unspecified
TX1029957-02Medicaid
TX102995702Medicaid
TXE56702Medicare UPIN