Provider Demographics
NPI:1568487825
Name:DE STEFANO, KIMBERLY (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:DE STEFANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12200 RENFERT WAY STE G-3
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-5654
Mailing Address - Country:US
Mailing Address - Phone:512-821-2540
Mailing Address - Fax:512-973-3533
Practice Address - Street 1:1583 E COMMON ST STE 111
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-3174
Practice Address - Country:US
Practice Address - Phone:830-629-2826
Practice Address - Fax:830-629-2841
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3614207V00000X, 207VM0101X
FLME96503207V00000X, 207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL56595OtherBLUE CROSS BLUE SHIELD
TX207918801Medicaid
FL276233400Medicaid
TX207918801Medicaid
FLU8523ZMedicare PIN
TX8F22990Medicare PIN