Provider Demographics
NPI:1386885499
Name:ROCKWALL MEDICAL ASSOCIATION, PA
Entity type:Organization
Organization Name:ROCKWALL MEDICAL ASSOCIATION, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:SHEPHERD
Authorized Official - Last Name:STILES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-771-1628
Mailing Address - Street 1:114 KENWAY ST
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-3536
Mailing Address - Country:US
Mailing Address - Phone:972-771-1628
Mailing Address - Fax:972-771-3670
Practice Address - Street 1:114 KENWAY ST
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-3536
Practice Address - Country:US
Practice Address - Phone:972-771-1628
Practice Address - Fax:972-771-3670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-19
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH-88532080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty