Provider Demographics
NPI:1427266857
Name:KINDRICK, STEPHEN DWAYNE (DO)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DWAYNE
Last Name:KINDRICK
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 1:731 E SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6377
Mailing Address - Country:US
Mailing Address - Phone:817-424-3366
Mailing Address - Fax:
Practice Address - Street 1:731 E SOUTHLAKE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6377
Practice Address - Country:US
Practice Address - Phone:817-424-3366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7334207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX202572801Medicaid
TX8L13370Medicare PIN
TXP00813435Medicare PIN