Provider Demographics
NPI:1871575100
Name:STALLMAN, KENNETH JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:JOHN
Last Name:STALLMAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:7909 FREDERICKSBURG RD
Mailing Address - Street 2:SUITE #110
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3425
Mailing Address - Country:US
Mailing Address - Phone:210-614-4544
Mailing Address - Fax:210-582-5522
Practice Address - Street 1:7909 FREDERICKSBURG RD
Practice Address - Street 2:SUITE #120,130
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3425
Practice Address - Country:US
Practice Address - Phone:210-614-4544
Practice Address - Fax:210-582-5522
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2009-08-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXM0931208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176324502Medicaid
TXI43549Medicare UPIN
TX176324502Medicaid