Provider Demographics
NPI:1245285022
Name:THALLER, EPHRAIM ISAAC
Entity type:Individual
Prefix:DR
First Name:EPHRAIM
Middle Name:ISAAC
Last Name:THALLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 LONDONDERRY DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-7900
Mailing Address - Country:US
Mailing Address - Phone:254-751-1144
Mailing Address - Fax:254-751-1185
Practice Address - Street 1:333 LONDONDERRY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7900
Practice Address - Country:US
Practice Address - Phone:254-751-1144
Practice Address - Fax:254-751-1185
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4144207KA0200X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180355301Medicaid
TX00712NOtherMEDICARE GROUP PTAN
P00428353OtherRAILROAD MEDICARE
151825100OtherFIRST CARE
8V9670OtherBCBS
TX180355301Medicaid