Provider Demographics
NPI:1164421285
Name:WALLENHAUPT, STEPHEN LEE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LEE
Last Name:WALLENHAUPT
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 1:1718 E 4TH ST
Mailing Address - Street 2:SUITE 701
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3261
Mailing Address - Country:US
Mailing Address - Phone:704-316-5100
Mailing Address - Fax:704-316-5101
Practice Address - Street 1:1718 E 4TH ST
Practice Address - Street 2:SUITE 701
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3261
Practice Address - Country:US
Practice Address - Phone:704-316-5100
Practice Address - Fax:704-316-5101
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26402208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8985522Medicaid
C86973Medicare UPIN