1013960228 NPI number — DR. RONALD WAYNE KILLAM MD

Table of content: DR. RONALD WAYNE KILLAM MD (NPI 1013960228)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013960228 NPI number — DR. RONALD WAYNE KILLAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KILLAM
Provider First Name:
RONALD
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1013960228
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 96706
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77213-6706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-330-0766
Provider Business Mailing Address Fax Number:
877-862-8370

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11110 EAST FWY STE 100A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77029-1914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-330-0766
Provider Business Practice Location Address Fax Number:
877-862-8370
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  H5715 , 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: 111525501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 111525504 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 810621291 . This is a "TAX IDENTIFICATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8Z1542 . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 111525505 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 460986471 . This is a "TAX IDENTIFICATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8K3280 . This is a "BLUE CROSS SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1518219104 . This is a "GROUP NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00511B . This is a "BLUECROSS BLUESHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 10014941 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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