Provider Demographics
NPI:1346424835
Name:STALLWORTH, CHRISTIAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:L
Last Name:STALLWORTH
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 1:21 SPURS LN STE 120
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-1670
Mailing Address - Country:US
Mailing Address - Phone:210-616-0301
Mailing Address - Fax:
Practice Address - Street 1:8300 FLOYD CURL DR
Practice Address - Street 2:MAIL CODE 7777
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3931
Practice Address - Country:US
Practice Address - Phone:210-450-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD29181207Y00000X
TXN6679207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX215321501Medicaid
TXTXB109106Medicare PIN