Provider Demographics
NPI:1700804937
Name:TRAVIS, WILLIAM RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RICHARD
Last Name:TRAVIS
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 1:4545 FULLER DR STE 325
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-6530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4545 FULLER DR STE 325
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-6530
Practice Address - Country:US
Practice Address - Phone:972-870-5511
Practice Address - Fax:972-870-5512
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8954207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX034025903Medicaid
TX360849YL2LMedicare PIN
TX034025902Medicaid