Provider Demographics
NPI:1114988045
Name:STEPHENSON, P DEE G (MD, PA)
Entity Type:Individual
Prefix:
First Name:P DEE
Middle Name:G
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:MD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PALERMO PLACE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285
Mailing Address - Country:US
Mailing Address - Phone:941-485-1121
Mailing Address - Fax:941-486-0571
Practice Address - Street 1:200 PALERMO PL
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2820
Practice Address - Country:US
Practice Address - Phone:941-485-1121
Practice Address - Fax:941-486-0571
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0051453207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058538001OtherDMERC
FL07275OtherBLUE CROSS BLUE SHIELD
FLFL0071799OtherTRICARE
624839OtherAETNA
FL063852800Medicaid
650058943OtherUNITED HEALTH CARE
D84955Medicare UPIN
FL058538001OtherDMERC
180006133Medicare PIN