Provider Demographics
NPI:1124191226
Name:STEPHAN, RUSSELL WADE (MSM MPT)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:WADE
Last Name:STEPHAN
Suffix:
Gender:M
Credentials:MSM MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9371 CYPRESS LAKE DR
Mailing Address - Street 2:SUITE 20
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-4939
Mailing Address - Country:US
Mailing Address - Phone:239-415-2595
Mailing Address - Fax:239-415-2597
Practice Address - Street 1:9371 CYPRESS LAKE DR
Practice Address - Street 2:SUITE 20
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-4939
Practice Address - Country:US
Practice Address - Phone:239-415-2595
Practice Address - Fax:239-415-2597
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT20296225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7849Medicare ID - Type Unspecified