Basic Information
| Provider Information | |||||||||
| NPI: | 1730181017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STETSON | ||||||||
| FirstName: | CLOYCE | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5865 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794085865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432898 | ||||||||
| FaxNumber: | 8067433596 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | SUITE 4A100 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794309400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067431842 | ||||||||
| FaxNumber: | 8067431105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | J9557 | TX | N | Allopathic & Osteopathic Physicians | Dermatology | 207ND0900X | J9557 | TX | Y | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology |
ID Information
| ID | Type | State | Issuer | Description | 119034002 | 05 | TX | MEDICAID | 119034001 | 05 | TX | MEDICAID | 80580S | 01 | TX | BC/BS | OTHER | 80948Z | 01 | TX | HMO BLUE | OTHER | 100163190A | 05 | OK | MEDICAID | S4956 | 05 | NM | MEDICAID | 124783101 | 05 | TX | MEDICAID | 124783100 | 01 | TX | FIRSTCARE COMMERCIAL | OTHER | 201021543 | 01 | NM | PRESBYTERIAN COMMERCIAL | OTHER | 201021543 | 05 | NM | MEDICAID | A363 | 01 | TRIWEST | OTHER |