Healthcare Provider Details

I. General information

NPI: 1518327691
Provider Name (Legal Business Name): STEPHAN JAVAHERI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 08/26/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86TH MEDICAL GROUP UNIT 3215
APO AE
09094-3215
US

IV. Provider business mailing address

86TH MEDICAL GROUP UNIT 3215
APO AE
09094-3215
US

V. Phone/Fax

Practice location:
  • Phone: 314-479-2609
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN22080
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: