Healthcare Provider Details

I. General information

NPI: 1114004462
Provider Name (Legal Business Name): RICHARD STOVALL MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 PARK BEND DR BLDG 2, STE 201
AUSTIN TX
78758-5388
US

IV. Provider business mailing address

PO BOX 25887
OKLAHOMA CITY OK
73125-0887
US

V. Phone/Fax

Practice location:
  • Phone: 512-835-8100
  • Fax: 512-835-8101
Mailing address:
  • Phone: 512-835-8100
  • Fax: 512-835-8101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberK5409
License Number StateTX

VIII. Authorized Official

Name: MANDY LYNN ONTIVEROS
Title or Position: OFFICE MANAGER
Credential:
Phone: 512-835-8100