Provider Demographics
NPI:1598781122
Name:STEPHENSON, GERALD ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:ROBERT
Last Name:STEPHENSON
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 732973
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-7329
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:817-702-8445
Practice Address - Street 1:1500 S MAIN ST STE 303
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-1172
Practice Address - Fax:817-702-1605
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL95032086X0206X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168027402Medicaid
P00254219OtherRAILROAD MEDICARE
TX168027402Medicaid