Provider Demographics
NPI:1306342431
Name:LINE, STEPHEN WESLEY (DO)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:WESLEY
Last Name:LINE
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:8441 STATE HWY 47
Mailing Address - Street 2:STE 3115
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77807
Mailing Address - Country:US
Mailing Address - Phone:979-436-9703
Mailing Address - Fax:
Practice Address - Street 1:3121 UNIVERSITY DR E STE 100
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3499
Practice Address - Country:US
Practice Address - Phone:979-776-0169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXS6243207Q00000X
TXBP10063117207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2J5586OtherMEDICARE