Provider Demographics
NPI:1083833602
Name:BYRUM, STEPHANIE COSTA (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:COSTA
Last Name:BYRUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 E. BANNER GATEWAY DRIVE
Mailing Address - Street 2:SUITE #450
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2165
Mailing Address - Country:US
Mailing Address - Phone:480-256-6444
Mailing Address - Fax:480-256-4734
Practice Address - Street 1:2646 E. BANNER GATEWAY DRIVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2165
Practice Address - Country:US
Practice Address - Phone:480-256-6444
Practice Address - Fax:480-256-4734
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36849208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ117323Medicare PIN
AZZ141533Medicare PIN
AZZ147706Medicare PIN