Provider Demographics
NPI:1336163054
Name:IM, STEPHEN S (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:S
Last Name:IM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:12500 JUDSON RD STE 205
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-4146
Mailing Address - Country:US
Mailing Address - Phone:210-655-6400
Mailing Address - Fax:210-655-6404
Practice Address - Street 1:12500 JUDSON RD STE 205
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-4146
Practice Address - Country:US
Practice Address - Phone:210-655-6400
Practice Address - Fax:210-655-6404
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2024-06-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXJ4232207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX105321702Medicaid
TX105321704Medicaid
TX00A0074Medicare PIN
TX105321704Medicaid
TX8F9494Medicare PIN
TX88630NMedicare PIN