Provider Demographics
NPI:1679602478
Name:ROSALES, STEPHEN R (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:ROSALES
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 1:1812 RUNNING BROOK DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-3458
Mailing Address - Country:US
Mailing Address - Phone:409-996-3310
Mailing Address - Fax:
Practice Address - Street 1:6300 LA CALMA DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78752-3843
Practice Address - Country:US
Practice Address - Phone:409-996-3310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24602207Q00000X, 207P00000X
TXN1434207P00000X, 207Q00000X
390200000X
LAMD.205596207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2199544Medicaid