Healthcare Provider Details

I. General information

NPI: 1841450616
Provider Name (Legal Business Name): STEPHEN E PAUL DO PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2008
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E MAIN ST
MAPLE SHADE NJ
08052-2679
US

IV. Provider business mailing address

111 E MAIN ST
MAPLE SHADE NJ
08052-2679
US

V. Phone/Fax

Practice location:
  • Phone: 856-779-9220
  • Fax: 856-779-7890
Mailing address:
  • Phone: 856-779-9220
  • Fax: 856-779-7890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB02548900
License Number StateNJ

VIII. Authorized Official

Name: DR. STEPHEN E. PAUL
Title or Position: PRESIDENT
Credential: D.O.
Phone: 856-779-9220