1013914498 NPI number — STEPHEN EDWARD EARLE M.D.

Table of content: STEPHEN EDWARD EARLE M.D. (NPI 1013914498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013914498 NPI number — STEPHEN EDWARD EARLE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EARLE
Provider First Name:
STEPHEN
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013914498
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 33577
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78265-3577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-872-6572
Provider Business Mailing Address Fax Number:
210-651-5137

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12315 JUDSON RD
Provider Second Line Business Practice Location Address:
# 208
Provider Business Practice Location Address City Name:
LIVE OAK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78233-3277
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-872-6572
Provider Business Practice Location Address Fax Number:
210-651-5137
Provider Enumeration Date:
06/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207XS0117X , with the licence number:  F3917 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X , with the licence number: F3917 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 169383001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 033081302 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201626736 . This is a "TAX ID #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 602044900 . This is a "U.S. DOL #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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