Provider Demographics
NPI:1073555173
Name:COLE, STEPHEN LEROY (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LEROY
Last Name:COLE
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 1:1310 E 7TH ST
Mailing Address - Street 2:DEKALB MEDICAL ARTS SUITE F
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-2534
Mailing Address - Country:US
Mailing Address - Phone:260-925-9511
Mailing Address - Fax:260-925-7626
Practice Address - Street 1:1310 E. 7TH STREET
Practice Address - Street 2:SUITE F
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-2518
Practice Address - Country:US
Practice Address - Phone:260-925-9511
Practice Address - Fax:260-925-7626
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INO102135614207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND67800Medicare UPIN
IN090430EEEEMedicare ID - Type Unspecified