Provider Demographics
NPI:1558364612
Name:STOLTENBERG, JEFFREY RONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:RONALD
Last Name:STOLTENBERG
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 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 NORTH PARK ST
Practice Address - Street 2:
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833-2610
Practice Address - Country:US
Practice Address - Phone:979-836-6153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5655208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAMERIGROUPOtherAMERIGROUP
TX10011289OtherSUPERIOR CHIPS
TX101240303Medicaid
TX8F23162Medicare PIN
TX10011289OtherSUPERIOR CHIPS