Provider Demographics
NPI:1912903238
Name:STANISLAW, SCOTT R (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:R
Last Name:STANISLAW
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 1:601 ROCKMEAD DR
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-2107
Mailing Address - Country:US
Mailing Address - Phone:713-486-7400
Mailing Address - Fax:281-359-2816
Practice Address - Street 1:601 ROCKMEAD DRIVE
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339
Practice Address - Country:US
Practice Address - Phone:713-486-7400
Practice Address - Fax:281-359-2816
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5219207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX096546903Medicaid
TX5116615OtherAETNA PROVIDER NUMBER
TXG09019Medicare UPIN
TX5116615OtherAETNA PROVIDER NUMBER