Provider Demographics
NPI:1790769297
Name:STEPHENSON, DOUGLAS (DO)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:DO
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 1325
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75671-1325
Mailing Address - Country:US
Mailing Address - Phone:903-927-6183
Mailing Address - Fax:903-927-6230
Practice Address - Street 1:622 S GROVE ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-5219
Practice Address - Country:US
Practice Address - Phone:903-927-6183
Practice Address - Fax:903-927-6230
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3236207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G0013Medicare ID - Type Unspecified
TXF77697Medicare UPIN