Provider Demographics
NPI:1225423726
Name:PAULSON, STEFANIE ANN (MD)
Entity Type:Individual
Prefix:MRS
First Name:STEFANIE
Middle Name:ANN
Last Name:PAULSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3401 CIVIC CENTER BLVD STE M975
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:7950 W JEFFERSON BLVD STE 210
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:260-435-7355
Practice Address - Fax:260-435-7637
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2023-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01080261A208000000X
PAMD479770208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program