Basic Information
| Provider Information | |||||||||
| NPI: | 1336230945 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESKIN | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | WILSON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 S TEXAS AVE | ||||||||
| Address2: | STE 102 | ||||||||
| City: | BRYAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778025361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9797742053 | ||||||||
| FaxNumber: | 9797765914 | ||||||||
| Practice Location | |||||||||
| Address1: | 5323 HARRY HINES BLVD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753907208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146450624 | ||||||||
| FaxNumber: | 2146450078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 12/15/2016 | ||||||||
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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 | 207YP0228X | D5962 | TX | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 137112214 | 05 | TX | MEDICAID |