Provider Demographics
NPI:1154349496
Name:ROBERTS, STOCKTON E (DO)
Entity type:Individual
Prefix:
First Name:STOCKTON
Middle Name:E
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 LIVE OAK ST STE 300
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-6149
Mailing Address - Country:US
Mailing Address - Phone:972-942-3410
Mailing Address - Fax:972-942-3411
Practice Address - Street 1:3310 LIVE OAK ST STE 300
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-6149
Practice Address - Country:US
Practice Address - Phone:972-942-3410
Practice Address - Fax:972-942-3411
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0224207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137425814Medicaid
TX137425813Medicaid
TX137425815Medicaid
TX137425815Medicaid
TX137425814Medicaid
TXF01368Medicare UPIN
TX137425813Medicaid