Provider Demographics
NPI:1962402040
Name:GANO, STEPHEN ERIK (MD)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:ERIK
Last Name:GANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1100 ORCHARD DR
Mailing Address - Street 2:STE B
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-2519
Mailing Address - Country:US
Mailing Address - Phone:817-860-3191
Mailing Address - Fax:817-860-0816
Practice Address - Street 1:1100 ORCHARD DR
Practice Address - Street 2:STE B
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-2519
Practice Address - Country:US
Practice Address - Phone:817-860-3191
Practice Address - Fax:817-860-0816
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXE7936207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP000KK601Medicaid
C15873Medicare UPIN
TXP000KK601Medicaid