Provider Demographics
NPI:1164477543
Name:STEFANO, JOHN L (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:STEFANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:302-733-2374
Mailing Address - Fax:302-733-2602
Practice Address - Street 1:4745 OGLETOWN-STANTON ROAD
Practice Address - Street 2:SUITE 217 MEDICAL ARTS PAVILION ONE
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713
Practice Address - Country:US
Practice Address - Phone:302-733-2374
Practice Address - Fax:302-733-2602
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC518122080N0001X
DECI00027512080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000096501Medicaid