Provider Demographics
NPI:1679593891
Name:STANTON, JERRY MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:MICHAEL
Last Name:STANTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:1600 CENTRAL DR
Mailing Address - Street 2:SUITE 160
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-6000
Mailing Address - Country:US
Mailing Address - Phone:817-268-0104
Mailing Address - Fax:817-268-6102
Practice Address - Street 1:1600 CENTRAL DR
Practice Address - Street 2:SUITE 160
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6000
Practice Address - Country:US
Practice Address - Phone:817-268-0104
Practice Address - Fax:817-268-6102
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1555208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA050033686OtherRAILROAD MEDICARE
TX86W010OtherBLUE CROSS BLUE SHIELD TX
TX180403400OtherDEPT OF LABOR LONDON KY
TX116585401Medicaid
TX528901OtherFIRST HEALTH
TXDOG1555OtherTEXAS WORK COMP
TX4389652OtherAETNA PPO
TX10028066OtherAMERIGROUP
MD006895499OtherEEOICP
TX2028260OtherAETNA HMO
TXDOG1555OtherTEXAS WORK COMP
TX86W010Medicare PIN