Provider Demographics
NPI:1982658381
Name:STAVROS, ANTHONY THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:THOMAS
Last Name:STAVROS
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 1:5253 PRUE RD
Mailing Address - Street 2:SUITE 315, BUILDING 3
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-1758
Mailing Address - Country:US
Mailing Address - Phone:707-849-6548
Mailing Address - Fax:
Practice Address - Street 1:5253 PRUE RD
Practice Address - Street 2:SUITE 315, BUILDING 3
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1758
Practice Address - Country:US
Practice Address - Phone:707-849-6548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO182552085R0202X
TXQ20692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX053211101Medicaid
KS200425010AMedicaid
CO300090435OtherRR RIA MCRE
WY117210700Medicaid
CO300090433OtherRR DIA MCRE
UT1982658381Medicaid
CO300048672OtherRR MIC MCRE
CO01182559Medicaid
MI104686383Medicaid
CO300090433OtherRR DIA MCRE
COC22154Medicare PIN
UT1982658381Medicaid
COC211808Medicare PIN