Healthcare Provider Details

I. General information

NPI: 1942219621
Provider Name (Legal Business Name): SEAN RAYL STEPHENSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 04/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 N LEROY ST
FENTON MI
48430-2729
US

IV. Provider business mailing address

305 N LEROY ST
FENTON MI
48430-2729
US

V. Phone/Fax

Practice location:
  • Phone: 810-629-0336
  • Fax: 810-629-7251
Mailing address:
  • Phone: 810-629-0336
  • Fax: 810-629-7251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number5101016669
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: