Provider Demographics
NPI:1235253246
Name:STEPHAN, ILENE FORREST (MD)
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:FORREST
Last Name:STEPHAN
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 1:856 J. CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-594-4006
Mailing Address - Fax:
Practice Address - Street 1:12420 WARWICK BLVD
Practice Address - Street 2:BUILDING 3, SUITE 4A
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606
Practice Address - Country:US
Practice Address - Phone:757-594-4431
Practice Address - Fax:757-594-2936
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101226300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1235253246Medicaid
VAVV1632AMedicare PIN
VAVV1632BMedicare PIN
VA1235253246Medicaid
VAVAA102151Medicare PIN
VAP00941745Medicare PIN
VAVAA102150Medicare PIN