Provider Demographics
NPI:1073715165
Name:BINGAMAN, STACIE LYNN (MD)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:LYNN
Last Name:BINGAMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:LYNN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1617 HEMPHILL ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4709
Mailing Address - Country:US
Mailing Address - Phone:817-702-2396
Mailing Address - Fax:817-927-3603
Practice Address - Street 1:400 W ARBROOK BLVD STE 300
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-3174
Practice Address - Country:US
Practice Address - Phone:972-647-8404
Practice Address - Fax:972-641-8398
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055347A207RE0101X
TXN2584207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX204165904Medicaid
TX204165906Medicaid
TX204165905Medicaid
TX204165906Medicaid
TXTXB113389Medicare PIN
TXTXB113390Medicare PIN