Provider Demographics
NPI:1013960228
Name:KILLAM, RONALD WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:WAYNE
Last Name:KILLAM
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:PO BOX 96406
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77213-6406
Mailing Address - Country:US
Mailing Address - Phone:713-330-0766
Mailing Address - Fax:877-862-8370
Practice Address - Street 1:11821 EAST FWY STE 175
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77029-1960
Practice Address - Country:US
Practice Address - Phone:713-330-0766
Practice Address - Fax:877-862-8370
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5715207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10014941Medicaid
TX8Z1542OtherBLUECROSS BLUESHIELD
TX111525501Medicaid
TX111525504Medicaid
TX810621291OtherTAX IDENTIFICATION
TX111525505Medicaid
TX1518219104OtherGROUP NPI
TX460986471OtherTAX IDENTIFICATION
TX00511BOtherBLUECROSS BLUESHIELD
TX8K3280OtherBLUE CROSS SHIELD
TX8Z1542OtherBLUECROSS BLUESHIELD
TX810621291OtherTAX IDENTIFICATION