Healthcare Provider Details

I. General information

NPI: 1932723020
Provider Name (Legal Business Name): ETHAN STEPHENS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 PATTONSVILLE RD
JACKSON OH
45640-9452
US

IV. Provider business mailing address

100 JACKSON PIKE
GALLIPOLIS OH
45631-1560
US

V. Phone/Fax

Practice location:
  • Phone: 740-446-5937
  • Fax: 740-395-8834
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34.016718
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: