Healthcare Provider Details

I. General information

NPI: 1629094735
Provider Name (Legal Business Name): IRINA F GERSHIN-STEVENS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22655 BAYSHORE RD STE 110
PORT CHARLOTTE FL
33980-2005
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 941-235-4900
  • Fax: 941-235-4901
Mailing address:
  • Phone: 239-343-9890
  • Fax: 239-343-9898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number225785
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberOS10700
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: