Basic Information
| Provider Information | |||||||||
| NPI: | 1104862226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STOLTZ | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 W MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173365060 | ||||||||
| FaxNumber: | 8173361744 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 W MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173365060 | ||||||||
| FaxNumber: | 8173361744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | E1766 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 1646440 | 01 | LA | UNISYS MEDICAID | OTHER | 834763 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 4036178 | 01 | AETNA | OTHER | 10013403 | 01 | AMERIGROUP | OTHER |