Provider Demographics
NPI:1104958230
Name:STAHL, BENJAMIN ADAM (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ADAM
Last Name:STAHL
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 1:1430 SOUTH MAIN STREET
Mailing Address - Street 2:SUITE 111
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006
Mailing Address - Country:US
Mailing Address - Phone:830-331-8585
Mailing Address - Fax:830-331-8586
Practice Address - Street 1:1430 SOUTH MAIN STREET
Practice Address - Street 2:SUITE 111
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006
Practice Address - Country:US
Practice Address - Phone:830-331-8585
Practice Address - Fax:830-331-8586
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1905207Q00000X, 390200000X
TXBP10025929390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX01287686Medicaid
TX8F22954Medicare PIN