Basic Information
| Provider Information | |||||||||
| NPI: | 1497711535 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AWAD | ||||||||
| FirstName: | REBHI | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4777 US HIGHWAY 259 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756057668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036634800 | ||||||||
| FaxNumber: | 9036637394 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 N GALLOWAY AVE | ||||||||
| Address2: | |||||||||
| City: | MESQUITE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751492433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143207008 | ||||||||
| FaxNumber: | 9724809024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 12/13/2011 | ||||||||
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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 | 2085R0202X | J0431 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 118724701 | 05 | TX | MEDICAID | P00059285 | 01 | TX | RRMA | OTHER |