Provider Demographics
NPI:1649344391
Name:PRADO, STEPHANIE MARIE (MD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:PRADO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 848510
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-8510
Mailing Address - Country:US
Mailing Address - Phone:904-446-3451
Mailing Address - Fax:904-446-3013
Practice Address - Street 1:1907 HIGHWAY 97 E
Practice Address - Street 2:SUITE 130
Practice Address - City:JOURDANTON
Practice Address - State:TX
Practice Address - Zip Code:78026-1537
Practice Address - Country:US
Practice Address - Phone:830-769-5919
Practice Address - Fax:904-446-3013
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9153174400000X, 208100000X, 2083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No174400000XOther Service ProvidersSpecialist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX010915507OtherTAX ID