Healthcare Provider Details

I. General information

NPI: 1992018378
Provider Name (Legal Business Name): NICOLA STEPANIAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4453 CASTOR AVE STE B
PHILADELPHIA PA
19124-3846
US

IV. Provider business mailing address

4453 CASTOR AVE STE B
PHILADELPHIA PA
19124-3846
US

V. Phone/Fax

Practice location:
  • Phone: 215-744-2266
  • Fax: 215-743-9247
Mailing address:
  • Phone: 215-744-2266
  • Fax: 215-743-9247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS015570
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberOS015570
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: