Basic Information
| Provider Information | |||||||||
| NPI: | 1205273802 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PELLI | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 841656 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752841656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 719 W COKE RD | ||||||||
| Address2: | |||||||||
| City: | WINNSBORO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754943011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033425227 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2013 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 207P00000X | BP10047337 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8HB331 | 01 | TX | BCBS | OTHER | 413557YS6P | 01 | TX | MEDICARE | OTHER | 346096614 | 05 | TX | MEDICAID | 75-0818167-044 | 01 | TX | TRICARE | OTHER | 75-0818167-048 | 01 | TX | TRICARE | OTHER | P01912520 | 01 | TX | MEDICARE RAIL ROAD | OTHER |