Provider Demographics
NPI:1871543660
Name:STEPHANIAN, EDIC (MD)
Entity type:Individual
Prefix:DR
First Name:EDIC
Middle Name:
Last Name:STEPHANIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 CLARA BARTON BLVD STE 350
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-5747
Mailing Address - Country:US
Mailing Address - Phone:972-426-9900
Mailing Address - Fax:972-426-9899
Practice Address - Street 1:601 CLARA BARTON BLVD STE 350
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-5747
Practice Address - Country:US
Practice Address - Phone:972-426-9900
Practice Address - Fax:972-426-9899
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6256208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123939402Medicaid
TXF30803Medicare UPIN
TX89090FMedicare ID - Type UnspecifiedMEDICARE NUMBER