Provider Demographics
NPI:1649242975
Name:BOSTER, STEPHEN RAY (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RAY
Last Name:BOSTER
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 1:611 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-4521
Mailing Address - Country:US
Mailing Address - Phone:325-657-5222
Mailing Address - Fax:
Practice Address - Street 1:120 E HARRIS AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-5904
Practice Address - Country:US
Practice Address - Phone:325-657-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8348207P00000X, 207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133676008Medicaid
TX0009MPOtherBLUECROSSBLUESHIELD
TX133676008Medicaid
TX8D0347Medicare ID - Type Unspecified
TX00819GMedicare PIN