Provider Demographics
NPI:1720101173
Name:PHILLEAUX, RONALD WREYBURN I (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:WREYBURN
Last Name:PHILLEAUX
Suffix:I
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 1:10246 MIDWAY RD
Mailing Address - Street 2:STE. 105
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75229-6233
Mailing Address - Country:US
Mailing Address - Phone:214-357-9481
Mailing Address - Fax:214-902-0636
Practice Address - Street 1:10246 MIDWAY RD
Practice Address - Street 2:SUITE 105
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75229-6233
Practice Address - Country:US
Practice Address - Phone:214-357-9481
Practice Address - Fax:214-902-0636
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD1883174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD1883OtherSTATE LICENSE NUMBER
TXB25498Medicare UPIN
TXD1883OtherSTATE LICENSE NUMBER