Healthcare Provider Details

I. General information

NPI: 1639664717
Provider Name (Legal Business Name): STEPHANIE PHAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 LIONEL WAY FL 3
DAVENPORT FL
33837-7809
US

IV. Provider business mailing address

500 E CENTRAL AVE
WINTER HAVEN FL
33880-3094
US

V. Phone/Fax

Practice location:
  • Phone: 863-293-1191
  • Fax: 863-837-5333
Mailing address:
  • Phone: 863-293-1191
  • Fax: 863-837-5333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS17951
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: