Provider Demographics
NPI:1326143561
Name:STOCKHAUSEN, AMY L (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:L
Last Name:STOCKHAUSEN
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:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-6483
Mailing Address - Fax:682-885-3113
Practice Address - Street 1:4443 N JOSEY LN STE 160
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4676
Practice Address - Country:US
Practice Address - Phone:972-492-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXT2072208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34211800Medicaid
WI34211800Medicaid
WI000338050Medicare ID - Type Unspecified