Provider Demographics
NPI:1720207947
Name:ROCKWALL MEDICAL ASSOCIATION PA
Entity Type:Organization
Organization Name:ROCKWALL MEDICAL ASSOCIATION PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:S
Authorized Official - Last Name:STILES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-288-7337
Mailing Address - Street 1:502 W KEARNEY ST
Mailing Address - Street 2:SUITE 700
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75149-3401
Mailing Address - Country:US
Mailing Address - Phone:972-288-7337
Mailing Address - Fax:972-289-9076
Practice Address - Street 1:502 W KEARNEY ST
Practice Address - Street 2:SUITE 700
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-3401
Practice Address - Country:US
Practice Address - Phone:972-288-7337
Practice Address - Fax:972-289-9076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH88532080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111465401Medicaid
TX111465402Medicaid
TX111465402Medicaid