Basic Information
Provider Information | |||||||||
NPI: | 1154385532 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PIERCE | ||||||||
FirstName: | STEPHEN | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2901 VIA FORTUNA | ||||||||
Address2: | SUITE 600 | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787467565 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5124026233 | ||||||||
FaxNumber: | 5128314170 | ||||||||
Practice Location | |||||||||
Address1: | 14904 CORDERO DR | ||||||||
Address2: |   | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787174533 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5124005211 | ||||||||
FaxNumber: | 5127613501 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/13/2006 | ||||||||
LastUpdateDate: | 02/06/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | H7481 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 097944503 | 05 | TX |   | MEDICAID |