Provider Demographics
NPI:1932460656
Name:STULL, MAMIE CATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:MAMIE
Middle Name:CATHERINE
Last Name:STULL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MAMIE
Other - Middle Name:
Other - Last Name:GROOMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-916-0439
Mailing Address - Fax:210-916-6658
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:FORT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-0439
Practice Address - Fax:210-916-6658
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101255255208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice