Provider Demographics
NPI:1497772081
Name:BROTHERTON, STEPHEN L (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:L
Last Name:BROTHERTON
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 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:817-332-4465
Practice Address - Street 1:1651 W ROSEDALE
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7437
Practice Address - Country:US
Practice Address - Phone:817-335-4316
Practice Address - Fax:817-336-2504
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3184207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120310105Medicaid
TX200045844OtherRAILROAD MEDICARE