Provider Demographics
NPI:1326097676
Name:STEPHENS, JEFFREY S (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:STEPHENS
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 1:4450 TUBBS RD
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-6308
Mailing Address - Country:US
Mailing Address - Phone:972-722-3290
Mailing Address - Fax:972-722-3815
Practice Address - Street 1:4450 TUBBS RD
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-6308
Practice Address - Country:US
Practice Address - Phone:972-722-3290
Practice Address - Fax:972-722-3815
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2983208600000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1093083560OtherGRP NPI
TX0999351OtherAMERIGROUP
TX265403YN0QOtherMCPTAN
TX36-412381OtherTIN #
TXJ2983OtherTEXAS LICENSE
TX099935106Medicaid
TXP01153365OtherRR MEDICARE