Provider Demographics
NPI:1205840758
Name:LAGERGREN, STEPHEN JONAS (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JONAS
Last Name:LAGERGREN
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:PO BOX 3087
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32781-3087
Mailing Address - Country:US
Mailing Address - Phone:321-264-1000
Mailing Address - Fax:321-264-4228
Practice Address - Street 1:1713 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-5002
Practice Address - Country:US
Practice Address - Phone:321-269-1621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0037125207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL22944Medicaid
FL05430ZMedicare ID - Type Unspecified
K0325Medicare ID - Type UnspecifiedGROUP NUMBER
FL22944Medicaid