Healthcare Provider Details

I. General information

NPI: 1346249315
Provider Name (Legal Business Name): STEFAN G HUMPHRIES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 MEMORIAL MEDICAL PKWY
DAYTONA BEACH FL
32117-5167
US

IV. Provider business mailing address

3152 LITTLE RD # 162
TRINITY FL
34655-1864
US

V. Phone/Fax

Practice location:
  • Phone: 386-231-6000
  • Fax:
Mailing address:
  • Phone: 847-289-5727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number14305
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number37261
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number26359
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberME148755
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: