1396945234 NPI number — WALLIS DERMATOLOGY ASSOCIATES PLLC

Table of content: MELANIE ELAINE ILITCH PA (NPI 1497043970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396945234 NPI number — WALLIS DERMATOLOGY ASSOCIATES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALLIS DERMATOLOGY ASSOCIATES PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396945234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3535 N FOURTH ST STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75605-0038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-757-3881
Provider Business Mailing Address Fax Number:
903-757-5948

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3535 N FOURTH ST STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75605-0038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-757-3881
Provider Business Practice Location Address Fax Number:
903-757-5948
Provider Enumeration Date:
07/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOWEN
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING OFFICER
Authorized Official Telephone Number:
903-503-7330

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  H6685 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 302333501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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