Provider Demographics
NPI:1790420305
Name:WOTTRICH, STEPHANIE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WOTTRICH
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 1:3308 SILKGRASS BND
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-5630
Mailing Address - Country:US
Mailing Address - Phone:512-658-1927
Mailing Address - Fax:
Practice Address - Street 1:1500 RED RIVER ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-1918
Practice Address - Country:US
Practice Address - Phone:512-324-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-28
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP100788332084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology