Provider Demographics
NPI:1093158370
Name:STEFANOS, RUTH WESSEN
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:WESSEN
Last Name:STEFANOS
Suffix:
Gender:F
Credentials:
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 2078
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-6156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:609 MEDICAL CENTER DR # 2218
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3836
Practice Address - Country:US
Practice Address - Phone:940-626-2718
Practice Address - Fax:940-626-1320
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ9746208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1093158370Medicaid
TX8KE37OtherBCBSTX