Provider Demographics
NPI:1285738930
Name:WEATHERFORD, STEPHEN C (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:C
Last Name:WEATHERFORD
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 1:2501 JIMMY JOHNSON BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77640-2000
Mailing Address - Country:US
Mailing Address - Phone:409-853-5288
Mailing Address - Fax:409-853-5274
Practice Address - Street 1:2501 JIMMY JOHNSON BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77640-2000
Practice Address - Country:US
Practice Address - Phone:409-853-5288
Practice Address - Fax:409-853-5274
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2098208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123423903Medicaid
89714FMedicare ID - Type Unspecified
TX123423903Medicaid