Healthcare Provider Details

I. General information

NPI: 1174838411
Provider Name (Legal Business Name): PHILIP R. WISIACKAS, M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2010
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HILL AVE
COLDSPRING TX
77331-5406
US

IV. Provider business mailing address

110 HILL AVE
COLDSPRING TX
77331-5406
US

V. Phone/Fax

Practice location:
  • Phone: 936-653-4223
  • Fax: 936-653-5042
Mailing address:
  • Phone: 936-653-4223
  • Fax: 936-653-5042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberF4703
License Number StateTX

VIII. Authorized Official

Name: PHILIP ROBERT WISIACKAS
Title or Position: PHYSICIAN
Credential: MD
Phone: 936-653-4223