Provider Demographics
NPI:1598762957
Name:STANTON, LONNIE (MD)
Entity Type:Individual
Prefix:DR
First Name:LONNIE
Middle Name:
Last Name:STANTON
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 1:351 N SAM HOUSTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN BENITO
Mailing Address - State:TX
Mailing Address - Zip Code:78586-4656
Mailing Address - Country:US
Mailing Address - Phone:956-399-2443
Mailing Address - Fax:956-399-6331
Practice Address - Street 1:351 N SAM HOUSTON BLVD
Practice Address - Street 2:
Practice Address - City:SAN BENITO
Practice Address - State:TX
Practice Address - Zip Code:78586-4656
Practice Address - Country:US
Practice Address - Phone:956-399-2443
Practice Address - Fax:956-399-6331
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6964208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX038772201Medicaid
TX080016232OtherMED RR
TX038772201Medicaid
TX080016232OtherMED RR