Provider Demographics
NPI:1780304915
Name:ROUGEAUX, RAY A
Entity type:Individual
Prefix:
First Name:RAY
Middle Name:A
Last Name:ROUGEAUX
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 1:12704 BRUCE DR
Mailing Address - Street 2:
Mailing Address - City:BALCH SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:75180-5301
Mailing Address - Country:US
Mailing Address - Phone:469-774-7483
Mailing Address - Fax:
Practice Address - Street 1:12704 BRUCE DR
Practice Address - Street 2:
Practice Address - City:BALCH SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:75180-5301
Practice Address - Country:US
Practice Address - Phone:469-774-7483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13045227171W00000X
343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXNONEMedicaid