Provider Demographics
NPI:1265471593
Name:REDWINE, WILLIAM A (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:A
Last Name:REDWINE
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 1:6624 FANNIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2336
Mailing Address - Country:US
Mailing Address - Phone:713-790-9151
Mailing Address - Fax:713-790-0927
Practice Address - Street 1:6624 FANNIN ST
Practice Address - Street 2:2400
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2312
Practice Address - Country:US
Practice Address - Phone:713-790-9151
Practice Address - Fax:713-790-0927
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD8396174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC20934Medicare UPIN
TX00HX27Medicare ID - Type Unspecified