Basic Information
| Provider Information | |||||||||
| NPI: | 1023088986 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STANLEY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3412 CLEAR FORK TRL | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761092409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177630945 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3001 E PRESIDENT GEORGE BUSH HWY | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | RICHARDSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750823542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724375099 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | F7930 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P085455F8 | 05 | TX | MEDICAID |