Provider Demographics
NPI:1053387399
Name:STEPHAN, PHILLIP JOHN (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:JOHN
Last Name:STEPHAN
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:PO BOX 1011
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76307-1011
Mailing Address - Country:US
Mailing Address - Phone:214-522-0210
Mailing Address - Fax:214-522-0474
Practice Address - Street 1:2200 KELL BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76309-4401
Practice Address - Country:US
Practice Address - Phone:940-264-2600
Practice Address - Fax:940-264-2601
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2679208600000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH88385Medicare UPIN