Provider Demographics
NPI:1053316562
Name:IRVIN, STEPHEN BRIAN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:BRIAN
Last Name:IRVIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 JABARRAH AVE
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR JOHNSON A F B
Mailing Address - State:NC
Mailing Address - Zip Code:27531-2310
Mailing Address - Country:US
Mailing Address - Phone:919-722-1580
Mailing Address - Fax:919-722-1956
Practice Address - Street 1:1050 JABARRAH AVE
Practice Address - Street 2:
Practice Address - City:SEYMOUR JOHNSON A F B
Practice Address - State:NC
Practice Address - Zip Code:27531-2310
Practice Address - Country:US
Practice Address - Phone:919-722-1580
Practice Address - Fax:919-722-1956
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001493207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC128N0OtherBCBS
NCP00451050OtherRAILROAD MEDICARE
NCD9807OtherMEDCOST
NC128N0OtherBCBS
NC2284123DMedicare PIN