Healthcare Provider Details

I. General information

NPI: 1730106410
Provider Name (Legal Business Name): ERICK STEPHANIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 LANDMARK DR STE B
LAFAYETTE IN
47905-6652
US

IV. Provider business mailing address

2625 E DIVISADERO ST
FRESNO CA
93721-1431
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-4100
  • Fax: 765-448-7610
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberG73185
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: