Provider Demographics
NPI:1144305384
Name:RAINE, WILFRED L (MD)
Entity type:Individual
Prefix:
First Name:WILFRED
Middle Name:L
Last Name:RAINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:3131 S CENTER ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-2007
Practice Address - Country:US
Practice Address - Phone:817-375-1413
Practice Address - Fax:817-261-0013
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2616208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2656885OtherCIGNA PIN
TX16395332OtherFIRSTHEALTH PIN
TXRAIWF64231OtherCCHIP PIN
TX140442848Medicaid
TX86963GOtherBCBSTX IND PIN
TX00U87ZOtherBCBSTX GRP PIN
TX121394403Medicaid
1750369203OtherGRP NPI NUMBER
TX121394404Medicaid
TX5619619OtherAETNA PIN
TX1446561OtherUHC PIN
TXRAIWF64231OtherCCHIP PIN
TX5619619OtherAETNA PIN
F64231Medicare UPIN