Provider Demographics
NPI:1356088140
Name:DOBSON, STEPHEN ANTONIO
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ANTONIO
Last Name:DOBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 BREWERY PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4544
Mailing Address - Country:US
Mailing Address - Phone:313-446-4444
Mailing Address - Fax:
Practice Address - Street 1:1333 BREWERY PARK BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4544
Practice Address - Country:US
Practice Address - Phone:313-446-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3662751919172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker