Healthcare Provider Details

I. General information

NPI: 1902902257
Provider Name (Legal Business Name): STANTON C. PACKARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 08/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4002 BURKE RD
PASADENA TX
77504-3451
US

IV. Provider business mailing address

4002 BURKE RD
PASADENA TX
77504-3451
US

V. Phone/Fax

Practice location:
  • Phone: 281-606-2020
  • Fax:
Mailing address:
  • Phone: 281-606-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberJ6641
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberJ6641
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: