Healthcare Provider Details

I. General information

NPI: 1104958230
Provider Name (Legal Business Name): BENJAMIN ADAM STAHL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 05/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 SOUTH MAIN STREET SUITE 111
BOERNE TX
78006
US

IV. Provider business mailing address

1430 SOUTH MAIN STREET SUITE 111
BOERNE TX
78006
US

V. Phone/Fax

Practice location:
  • Phone: 830-331-8585
  • Fax: 830-331-8586
Mailing address:
  • Phone: 830-331-8585
  • Fax: 830-331-8586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberN1905
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10025929
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberN1905
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: