Healthcare Provider Details

I. General information

NPI: 1154596898
Provider Name (Legal Business Name): STEPHAN M. ESSER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 PONTE VEDRA PARK DR
PONTE VEDRA BEACH FL
32082-6600
US

IV. Provider business mailing address

6500 BOWDEN RD SUITE 103
JACKSONVILLE FL
32216-8070
US

V. Phone/Fax

Practice location:
  • Phone: 904-634-0640
  • Fax: 904-634-0203
Mailing address:
  • Phone: 904-634-0640
  • Fax: 904-634-0203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number149124
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME112692
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: