Provider Demographics
NPI:1245232446
Name:UPDEGRAFF, STEPHEN AMBROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:AMBROSE
Last Name:UPDEGRAFF
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 1:1601 38TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-1926
Mailing Address - Country:US
Mailing Address - Phone:727-822-4287
Mailing Address - Fax:727-822-4287
Practice Address - Street 1:1601 38TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-1926
Practice Address - Country:US
Practice Address - Phone:727-822-4287
Practice Address - Fax:727-822-4287
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0067224207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26428ZMedicare ID - Type Unspecified
FL4403500001Medicare NSC
FLF55113Medicare UPIN