Basic Information
| Provider Information | |||||||||
| NPI: | 1013983774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | THEODORE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6301 GASTON AVE | ||||||||
| Address2: | SUITE 100 WEST TOWER | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752143922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148273610 | ||||||||
| FaxNumber: | 2144439640 | ||||||||
| Practice Location | |||||||||
| Address1: | 6301 GASTON AVE | ||||||||
| Address2: | SUITE 100 WEST TOWER | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752143922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2148273610 | ||||||||
| FaxNumber: | 2144439640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 09/08/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | F9951 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 123466802 | 05 | TX | MEDICAID |