Provider Demographics
NPI:1114938453
Name:HARTSOCK, STEPHEN J (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:J
Last Name:HARTSOCK
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 - PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1115 RONALD REAGAN PKWY
Practice Address - Street 2:STE 148
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-6910
Practice Address - Country:US
Practice Address - Phone:317-962-8893
Practice Address - Fax:317-962-6722
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110046174400000X
IN01072804A207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No174400000XOther Service ProvidersSpecialist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL336070768OtherCONTROLLED SUBSTANCE #
IN201166240Medicaid
ILBH8994003OtherDEA #
IN068010025Medicare PIN
ILBH8994003OtherDEA #
IN264430113Medicare PIN
ININ1546003Medicare PIN