Healthcare Provider Details

I. General information

NPI: 1427369321
Provider Name (Legal Business Name): SHANE STEPHENSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16120 W DODGE RD
OMAHA NE
68118-2049
US

IV. Provider business mailing address

PO BOX 3755
OMAHA NE
68103-0755
US

V. Phone/Fax

Practice location:
  • Phone: 402-354-0610
  • Fax: 402-354-0611
Mailing address:
  • Phone: 402-354-2100
  • Fax: 402-354-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2010018000
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number29910
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: