Healthcare Provider Details

I. General information

NPI: 1396983326
Provider Name (Legal Business Name): REBECCA ELIZABETH RAWALT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2009
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 S 31ST ST
TEMPLE TX
76508-0001
US

IV. Provider business mailing address

PO BOX 847408
DALLAS TX
75284-7408
US

V. Phone/Fax

Practice location:
  • Phone: 254-724-2111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM8942
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number14401
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: