Provider Demographics
NPI:1285639583
Name:STEPHENSON, TEDDIE R (DC)
Entity Type:Individual
Prefix:DR
First Name:TEDDIE
Middle Name:R
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 BRIARCREST DR
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-5232
Mailing Address - Country:US
Mailing Address - Phone:979-776-2828
Mailing Address - Fax:979-776-2829
Practice Address - Street 1:1313 BRIARCREST DR
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-5232
Practice Address - Country:US
Practice Address - Phone:979-776-2828
Practice Address - Fax:979-776-2829
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2007-07-08
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
TXDC2854111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX601095Medicare ID - Type Unspecified
TXT16103Medicare UPIN