Provider Demographics
NPI:1245699511
Name:STOCKTON ROBERTS HEALTH CENTER, PLLC
Entity type:Organization
Organization Name:STOCKTON ROBERTS HEALTH CENTER, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STOCKTON
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-965-2551
Mailing Address - Street 1:145 MANUFACTURING ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75207-6401
Mailing Address - Country:US
Mailing Address - Phone:214-828-4702
Mailing Address - Fax:214-828-4890
Practice Address - Street 1:145 MANUFACTURING ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75207-6401
Practice Address - Country:US
Practice Address - Phone:214-828-4702
Practice Address - Fax:214-828-4890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-16
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0224207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137425821Medicaid
TX137425821Medicaid
TX353756ZKCSMedicare PIN