Healthcare Provider Details

I. General information

NPI: 1053316562
Provider Name (Legal Business Name): STEPHEN BRIAN IRVIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 10/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 JABARRAH AVE
SEYMOUR JOHNSON A F B NC
27531-2310
US

IV. Provider business mailing address

1050 JABARRAH AVE
SEYMOUR JOHNSON A F B NC
27531-2310
US

V. Phone/Fax

Practice location:
  • Phone: 919-722-1580
  • Fax: 919-722-1956
Mailing address:
  • Phone: 919-722-1580
  • Fax: 919-722-1956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number200001493
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number200001493
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: