Provider Demographics
NPI:1487686309
Name:SPAIN, STEPHEN C (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:C
Last Name:SPAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:5040 KINSEY DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3005
Mailing Address - Country:US
Mailing Address - Phone:903-561-8300
Mailing Address - Fax:903-561-8327
Practice Address - Street 1:5040 KINSEY DR
Practice Address - Street 2:SUITE 300
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3005
Practice Address - Country:US
Practice Address - Phone:903-561-8300
Practice Address - Fax:903-561-8327
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXG0154207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133341103Medicaid
TX010054743OtherRAILROAD MEDICARE
TX89X859OtherBLUE CROSS
TX133341103Medicaid
C22090Medicare UPIN
TX89X859Medicare PIN