Provider Demographics
NPI:1326129206
Name:PAETZOLD, STANLEY CARL (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:CARL
Last Name:PAETZOLD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2101 S COULTER ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-2513
Mailing Address - Country:US
Mailing Address - Phone:806-350-7744
Mailing Address - Fax:806-350-7776
Practice Address - Street 1:2101 S COULTER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106
Practice Address - Country:US
Practice Address - Phone:806-350-7744
Practice Address - Fax:806-350-7776
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-46442207P00000X
TXK3375207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM02320045Medicaid
OK200033590AMedicaid
TX110700503Medicaid
14148503OtherCAQH
KS04-46442OtherSTATE MEDICAL LICENSE
TX82940GOtherBLUE CROSS & BLUE SHIELD
TX930053181Medicare PIN