Provider Demographics
NPI:1912966938
Name:STEPHAN, MICHEL KHAMIS (MD)
Entity type:Individual
Prefix:
First Name:MICHEL
Middle Name:KHAMIS
Last Name:STEPHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2540 NTH GALLOWAY AVENUE
Mailing Address - Street 2:101
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150
Mailing Address - Country:US
Mailing Address - Phone:972-226-0405
Mailing Address - Fax:972-270-4959
Practice Address - Street 1:2540 NTH GALLOWAY AVENUE
Practice Address - Street 2:101
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150
Practice Address - Country:US
Practice Address - Phone:972-226-0405
Practice Address - Fax:972-270-4959
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF8687208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123330601Medicaid
TXC22231Medicare UPIN
TX123330601Medicaid