Provider Demographics
NPI:1336163054
Name:IM, STEPHEN S (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:S
Last Name:IM
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 1:12709 TOEPPERWEIN RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78233
Mailing Address - Country:US
Mailing Address - Phone:210-655-6400
Mailing Address - Fax:210-655-6404
Practice Address - Street 1:12709 TOEPPERWEIN RD
Practice Address - Street 2:SUITE 201
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3258
Practice Address - Country:US
Practice Address - Phone:210-655-6400
Practice Address - Fax:210-655-6404
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4232207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX105321704Medicaid
TX105321702Medicaid
TX00A0074Medicare PIN
TX105321704Medicaid
TX8F9494Medicare PIN
TX88630NMedicare PIN