Provider Demographics
NPI:1376556019
Name:AWTREY, STATON (MD)
Entity Type:Individual
Prefix:DR
First Name:STATON
Middle Name:
Last Name:AWTREY
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 1:4214 ANDREWS HWY STE 240
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79703-4817
Mailing Address - Country:US
Mailing Address - Phone:432-686-6600
Mailing Address - Fax:432-682-2284
Practice Address - Street 1:400 ROSALIND REDFERN GROVER PKWY STE 200
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-5852
Practice Address - Country:US
Practice Address - Phone:432-221-2107
Practice Address - Fax:432-221-5218
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6019207RC0000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147713503OtherMEDICAID - MIDLAND - PFC
TX8663J0OtherBCBS AUSTIN ID NUMBER
TX8663JOOtherMEDICARE PIN SAN ANGELO
TXTXB138584OtherTX MEDICARE-PREMIER
TX85010XOtherBCBS SAN ANGELO ID NUMBER
TXTXB138584OtherMIDLAND MEDICARE NUMBER
TX147713501Medicaid
TXTXB138584OtherTX MEDICARE-PREMIER
TX74-1796484OtherTAX ID NUMBER