Provider Demographics
NPI:1093754756
Name:MABERRY, STEPHEN D (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:D
Last Name:MABERRY
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 1:1200 W ROSEDALE ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4454
Mailing Address - Country:US
Mailing Address - Phone:817-336-8131
Mailing Address - Fax:
Practice Address - Street 1:1200 W ROSEDALE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4454
Practice Address - Country:US
Practice Address - Phone:817-336-8131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4317207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX085719501Medicaid
TX752656556OtherTAX ID #
TX070009295Medicare PIN
TX752656556OtherTAX ID #
TX085719501Medicaid
85Z005Medicare PIN