Provider Demographics
NPI:1619065703
Name:SUMNER, STEPHANIE L (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:SUMNER
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:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:801 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2733
Practice Address - Country:US
Practice Address - Phone:682-885-1475
Practice Address - Fax:682-885-7520
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0297208M00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0003GSOtherBCBSTX GRP PIN
TX4644820OtherAETNA PIN
TX080626701Medicaid
TX82V073OtherBCBSTX IND PIN
TX10028752OtherAMERIGROUP PIN
TX103393804Medicaid
TX125048100OtherFIRSTCARE PIN
TX163314101Medicaid
TX124049OtherSUPERIOR PIN
TX6707113OtherCIGNA PIN
TX103393803Medicaid
TX1640398OtherFIRSTHEALTH PIN
1124098447OtherGRP NPI NUMBER
TX163314101Medicaid