Provider Demographics
NPI:1154379428
Name:HUMPHREY, STEPHEN M (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:HUMPHREY
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 1:8135 FOREST LN # 515057
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2472
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2701 S HAMPTON RD STE 220B
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75224-2363
Practice Address - Country:US
Practice Address - Phone:866-552-4866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI444602085R0204X
IL0361064502085R0204X, 2085R0202X
TXN13492085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34237200Medicaid
WIH14736Medicare UPIN
WI34237200Medicaid
WI001101250Medicare PIN
IL789511Medicare PIN
ILF400136587Medicare PIN
IL789510Medicare PIN