Provider Demographics
NPI:1346443769
Name:DUBLIS, STEPHANIE A (DO)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:DUBLIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:MEDICAL ADMINISTRATION
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3200
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:5950 METRO WAY SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9514
Practice Address - Country:US
Practice Address - Phone:616-252-8100
Practice Address - Fax:616-252-8181
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118165207R00000X
MI5101019594207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101019594OtherSTATE LICENSE
MI0P59060015Medicare PIN