Healthcare Provider Details

I. General information

NPI: 1376561613
Provider Name (Legal Business Name): STEPHEN STEPHENSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1663 CAMPUS PARK DR SUITE D
MONROE NC
28112-5581
US

IV. Provider business mailing address

11301 CARMEL COMMONS BLVD STE 302
CHARLOTTE NC
28226-5305
US

V. Phone/Fax

Practice location:
  • Phone: 704-291-2488
  • Fax: 704-283-0160
Mailing address:
  • Phone: 704-372-7974
  • Fax: 704-372-8201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number200400415
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: