Provider Demographics
NPI:1033230560
Name:COURSON POTHOVEN, STEPHANIE LYNN (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:LYNN
Last Name:COURSON POTHOVEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:12129 UNIVERSITY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8287
Mailing Address - Country:US
Mailing Address - Phone:515-400-3550
Mailing Address - Fax:515-400-3551
Practice Address - Street 1:12129 UNIVERSITY AVE STE 100
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8287
Practice Address - Country:US
Practice Address - Phone:515-400-3550
Practice Address - Fax:515-400-3551
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IADO-03795208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1033230560Medicare PIN