Provider Demographics
NPI:1124095815
Name:STODDARD, DAVID L (CRNA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:STODDARD
Suffix:
Gender:M
Credentials:CRNA
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 650426
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0426
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:
Practice Address - Street 1:575 HILL COUNTRY DR STE 101
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-6024
Practice Address - Country:US
Practice Address - Phone:830-258-7828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX658772367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
072545OtherRE-CERT #
TX172979001Medicaid
TX8960UCOtherBCBS PINNACLE ANESTHESIA CONSULTANTS, PA
TX8D1570OtherBCBS PROV #
OK200050370AMedicaid
TXTXB155606Medicare PIN
P00185756Medicare ID - Type UnspecifiedRR PROV #
TX172979001Medicaid