Provider Demographics
NPI:1245248608
Name:MAILLOUX, RAYMOND J (MD)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:J
Last Name:MAILLOUX
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 1:6006 FIRECREST DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75044-4208
Mailing Address - Country:US
Mailing Address - Phone:903-814-5955
Mailing Address - Fax:
Practice Address - Street 1:1000 S FM 1417
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-4865
Practice Address - Country:US
Practice Address - Phone:903-892-2133
Practice Address - Fax:903-893-6317
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2010-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9787207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
06701680675OtherMEDICAL EDUCATION NUMBER
TX0981532-01Medicaid
TXEJ34Medicare ID - Type Unspecified
TXC18692Medicare UPIN