Provider Demographics
NPI:1629018395
Name:ORTHOPEDIC AND SPORTS MEDICINE
Entity Type:Organization
Organization Name:ORTHOPEDIC AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:DEGNAN
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-870-7936
Mailing Address - Street 1:321 N HIGHLAND AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75092
Mailing Address - Country:US
Mailing Address - Phone:903-870-7936
Mailing Address - Fax:903-957-0367
Practice Address - Street 1:321 N HIGHLAND AVE STE 120
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-7371
Practice Address - Country:US
Practice Address - Phone:903-870-7936
Practice Address - Fax:903-957-0367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX079825801Medicaid
OK100755120AMedicaid
TX0095CGOtherBLUE CROSS BLUE SHIELD
OK100755120AMedicaid
TX00086FMedicare PIN