Provider Demographics
NPI:1750484069
Name:PHILLIPP, KATHLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:PHILLIPP
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 1198
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79604-1198
Mailing Address - Country:US
Mailing Address - Phone:325-670-4220
Mailing Address - Fax:325-670-4040
Practice Address - Street 1:301 E 12TH ST
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TX
Practice Address - Zip Code:79556-2317
Practice Address - Country:US
Practice Address - Phone:325-235-2869
Practice Address - Fax:325-235-2842
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2615208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX096494201Medicaid
TX096494201Medicaid