Provider Demographics
NPI:1336308113
Name:STEPANOV, SERGEY (DO)
Entity Type:Individual
Prefix:
First Name:SERGEY
Middle Name:
Last Name:STEPANOV
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14501 MONTFORT DR
Mailing Address - Street 2:APT #1502
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-8546
Mailing Address - Country:US
Mailing Address - Phone:936-931-8088
Mailing Address - Fax:
Practice Address - Street 1:14501 MONTFORT DR
Practice Address - Street 2:APT #1502
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-8546
Practice Address - Country:US
Practice Address - Phone:936-931-8088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1462207R00000X, 207P00000X, 208100000X
NY248715207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation