Provider Demographics
NPI:1235667650
Name:STEGALL, ERICA DENISE (CST, CSFA)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:DENISE
Last Name:STEGALL
Suffix:
Gender:F
Credentials:CST, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 BIRCH RD
Mailing Address - Street 2:
Mailing Address - City:BIG SANDY
Mailing Address - State:TX
Mailing Address - Zip Code:75755-4628
Mailing Address - Country:US
Mailing Address - Phone:903-360-7991
Mailing Address - Fax:
Practice Address - Street 1:1040 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2031
Practice Address - Country:US
Practice Address - Phone:903-533-8702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1732892086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery