Provider Demographics
NPI:1720297765
Name:PEVEY, RYAN ROGERS (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:ROGERS
Last Name:PEVEY
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:PO BOX 610393
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75261-0393
Mailing Address - Country:US
Mailing Address - Phone:903-291-6187
Mailing Address - Fax:903-237-1810
Practice Address - Street 1:707 HOLLYBROOK DR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2410
Practice Address - Country:US
Practice Address - Phone:903-234-1830
Practice Address - Fax:903-753-6634
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5334208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX214484203Medicaid
TXTXB147324Medicare PIN