=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093780132
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN EDWARD STEPHENS JR. M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2006
-----------------------------------------------------
Last Update Date | 12/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3377 S STATE ROAD 7 STE 100
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33449-8002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-341-7000
-----------------------------------------------------
Fax | 561-341-7055
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2900 CORPORATE WAY DOOR D
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33025-3925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-276-5603
-----------------------------------------------------
Fax | 954-985-7074
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0206X
-----------------------------------------------------
Taxonomy Name | Pediatric Gastroenterology Physician
-----------------------------------------------------
License Number | ME 92461
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------