MEDICARE: PHILLIP H DISRAELI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	K5904	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104858380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP H DISRAELI MD

Provider Business Mailing Address
First Line	:	1700 FM 544 STE 200
Second Line	:
City	:	LEWISVILLE
State	:	TX
Zip	:	75056-4915
Country	:	US
Telephone Number	:	469-800-4250
Fax Number	:	469-800-4260

Provider Business Practice Location Address
First Line	:	1700 FM 544 STE 200
Second Line	:
City	:	LEWISVILLE
State	:	TX
Zip	:	75056-4915
Country	:	US
Telephone Number	:	469-800-4250
Fax Number	:	469-800-4260

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	01/19/2023

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Directions to “ PHILLIP H DISRAELI MD” Practice Location

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