Provider Demographics
NPI:1063467843
Name:PENCA, STEPHEN J (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:J
Last Name:PENCA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:972-715-9976
Practice Address - Street 1:6606 LBJ FWY
Practice Address - Street 2:SUITE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6533
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8811207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01357148OtherRR
TX113917208Medicaid
TX8EH652OtherBCBS
TX8EH652OtherBCBS
TXP01357148OtherRR
TX340355YK6UMedicare PIN