Provider Demographics
NPI:1164405544
Name:STURDIVANT, TED SHAWN (MD)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:SHAWN
Last Name:STURDIVANT
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 1:1007 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-4145
Mailing Address - Country:US
Mailing Address - Phone:956-454-6114
Mailing Address - Fax:
Practice Address - Street 1:900 S BRYAN RD
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:TX
Practice Address - Zip Code:78572-6613
Practice Address - Country:US
Practice Address - Phone:956-580-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9576207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8R0705OtherBCBS
TX8R0705OtherBCBS
TX00938QMedicare ID - Type Unspecified
TX8C1102Medicare ID - Type Unspecified
TXF31491Medicare UPIN