Provider Demographics
NPI:1750492948
Name:RIES, PENELOPE A (DO)
Entity Type:Individual
Prefix:DR
First Name:PENELOPE
Middle Name:A
Last Name:RIES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 E SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6377
Mailing Address - Country:US
Mailing Address - Phone:817-424-3366
Mailing Address - Fax:817-424-3426
Practice Address - Street 1:731 E SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6377
Practice Address - Country:US
Practice Address - Phone:817-424-3366
Practice Address - Fax:817-424-3426
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3415207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AD144OtherBCBS
TX8K5175Medicare PIN
P00696074Medicare PIN
TX8AD144OtherBCBS