Basic Information
| Provider Information | |||||||||
| NPI: | 1326009671 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KODACK | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | LOIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 N SARAH DEWITT DR | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786293311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306728502 | ||||||||
| FaxNumber: | 8306723035 | ||||||||
| Practice Location | |||||||||
| Address1: | 1110 N SARAH DEWITT DR | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786293311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306728502 | ||||||||
| FaxNumber: | 8306723035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 11/12/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | TX | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0349045-01 | 05 | TX | MEDICAID |