Healthcare Provider Details

I. General information

NPI: 1295730968
Provider Name (Legal Business Name): STEPHEN WOMACK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 03/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 N 6TH ST
LONGVIEW TX
75601-5532
US

IV. Provider business mailing address

906 N 6TH ST
LONGVIEW TX
75601-5532
US

V. Phone/Fax

Practice location:
  • Phone: 903-753-2246
  • Fax: 903-753-4470
Mailing address:
  • Phone: 903-753-2246
  • Fax: 903-753-4470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberK1136
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: