Provider Demographics
NPI:1174502801
Name:VERNON, STEPHEN G (DO)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:G
Last Name:VERNON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 S US 301
Mailing Address - Street 2:
Mailing Address - City:SUMTERVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:33585-5141
Mailing Address - Country:US
Mailing Address - Phone:352-793-5900
Mailing Address - Fax:352-793-6269
Practice Address - Street 1:1425 S US 301
Practice Address - Street 2:
Practice Address - City:SUMTERVILLE
Practice Address - State:FL
Practice Address - Zip Code:33585-5141
Practice Address - Country:US
Practice Address - Phone:352-793-5900
Practice Address - Fax:352-793-6269
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12788207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014061400Medicaid
MD795005500Medicaid
G84586Medicare UPIN