Provider Demographics
NPI:1114913969
Name:PERSHING, STEPHEN D (MD LLC)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:D
Last Name:PERSHING
Suffix:
Gender:M
Credentials:MD LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1559 HIGHLAND PARK DR
Mailing Address - Street 2:
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37772-6237
Mailing Address - Country:US
Mailing Address - Phone:865-635-8382
Mailing Address - Fax:865-635-8388
Practice Address - Street 1:1559 HIGHLAND PARK DR
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37772-6237
Practice Address - Country:US
Practice Address - Phone:865-635-8382
Practice Address - Fax:423-635-8388
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000010526207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNB03943Medicare UPIN
TN3086606Medicare ID - Type Unspecified