Provider Demographics
NPI:1326278110
Name:STEPHENS, BRENT (MD)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:STEPHENS
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-361-5626
Mailing Address - Fax:
Practice Address - Street 1:205 E NASA BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1950
Practice Address - Country:US
Practice Address - Phone:321-361-5626
Practice Address - Fax:321-723-9176
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-15
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME119690207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14V76OtherBCBS
FLHW451XOtherMEDICARE
FL012130500Medicaid
FLHW451YOtherHFPSI MEDICARE