Provider Demographics
NPI:1336111996
Name:RALEY, STEPHEN PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:PAUL
Last Name:RALEY
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:PO BOX 848476
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-8476
Mailing Address - Country:US
Mailing Address - Phone:254-202-4655
Mailing Address - Fax:254-202-4697
Practice Address - Street 1:1001 HEWITT DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712
Practice Address - Country:US
Practice Address - Phone:254-202-7800
Practice Address - Fax:254-202-7856
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8831207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131813104Medicaid
TX80Y493OtherBCBS
TX131813104Medicaid
TX80Y493OtherBCBS
C20784Medicare UPIN
080037918Medicare PIN