Provider Demographics
NPI:1124193743
Name:STEFOVIC, JOHN WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
Last Name:STEFOVIC
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 1:530 CENTRE STREET
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:PA
Mailing Address - Zip Code:17921
Mailing Address - Country:US
Mailing Address - Phone:570-875-0700
Mailing Address - Fax:570-875-1279
Practice Address - Street 1:530 CENTRE STREET
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:PA
Practice Address - Zip Code:17921
Practice Address - Country:US
Practice Address - Phone:570-875-0700
Practice Address - Fax:570-875-1279
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-034546-E208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0171850OtherHIGHMARK BLUE SHIELD
PA080122224OtherRAILROAD MEDICARE
03267500OtherKEYSTONE SENIOR BLUE
PA0014134440008Medicaid
PA010001700OtherBLACK LUNG
PA03267500OtherCAPITAL BLUE CROSS
03267500OtherKEYSTONE SENIOR BLUE
PA171850Medicare ID - Type Unspecified