Provider Demographics
NPI:1013914498
Name:EARLE, STEPHEN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:EDWARD
Last Name:EARLE
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:PO BOX 33577
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78265-3577
Mailing Address - Country:US
Mailing Address - Phone:210-872-6572
Mailing Address - Fax:210-651-5137
Practice Address - Street 1:12315 JUDSON RD
Practice Address - Street 2:# 208
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3277
Practice Address - Country:US
Practice Address - Phone:210-872-6572
Practice Address - Fax:210-651-5137
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3917207XS0117X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX169383001Medicaid
TX033081302Medicaid
TX201626736OtherTAX ID #
TX602044900OtherU.S. DOL #
TX033081302Medicaid
TX602044900OtherU.S. DOL #
TX00601XMedicare ID - Type UnspecifiedGROUP MEDICARE #