Healthcare Provider Details

I. General information

NPI: 1821797218
Provider Name (Legal Business Name): JESSE STUTZMAN MD, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2023
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 SONGTAN BLVD, 2060
APO AP
92678-2060
US

IV. Provider business mailing address

51 MEDICAL GROUP, OSAN AIR BASE
APO AP
92678-2060
US

V. Phone/Fax

Practice location:
  • Phone: 315-784-9111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101283320
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: