Individual
ELLEN STOCKTON WALRAVEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
520 DOUGLAS BLVD, TYLER, TX 75702-8307
(903) 593-1721
Mailing address
PO BOX 846098, DALLAS, TX 75284-6098
(903) 324-6400
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
H7843
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
099129105
—
TX
01
—
75-2616977-007
TRICARE
TX
01
—
8GQ837
BCBS
TX
Enumeration date
05/27/2006
Last updated
05/08/2017
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