Basic Information
| Provider Information | |||||||||
| NPI: | 1952386104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARSON HENDERSON | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 732973 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753732973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177022450 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177026500 | ||||||||
| FaxNumber: | 8179276559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 10/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | L4878 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 8A0452 | 01 | TX | BCBS | OTHER | 8DP282 | 01 | TX | BCBS | OTHER | P01379268 | 01 | TX | RAILROAD MEDICARE | OTHER | 1578189-01 | 05 | TX | MEDICAID | 157818903 | 05 | TX | MEDICAID |