Provider Demographics
NPI:1659379592
Name:VOLLENWEIDER, GARY M (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:M
Last Name:VOLLENWEIDER
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 1:1283 RECORD CROSSING RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-6001
Mailing Address - Country:US
Mailing Address - Phone:214-941-1050
Mailing Address - Fax:
Practice Address - Street 1:1283 RECORD CROSSING RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-6001
Practice Address - Country:US
Practice Address - Phone:214-941-1050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0909207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84T991Medicare ID - Type Unspecified
TXB27362Medicare UPIN
TX8J5518Medicare PIN
TX8J5210Medicare PIN