Provider Demographics
NPI:1326009671
Name:KODACK, STEPHANIE LOIS (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:LOIS
Last Name:KODACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 N SARAH DEWITT DR
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:TX
Mailing Address - Zip Code:78629-3311
Mailing Address - Country:US
Mailing Address - Phone:830-672-8502
Mailing Address - Fax:830-672-3035
Practice Address - Street 1:1110 N SARAH DEWITT DR
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:TX
Practice Address - Zip Code:78629-3311
Practice Address - Country:US
Practice Address - Phone:830-672-8502
Practice Address - Fax:830-672-3035
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0349045-01Medicaid
TX0349045-01Medicaid
TXOOMN94Medicare ID - Type Unspecified