Provider Demographics
NPI:1376500264
Name:STEFANE, ALLEN
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:
Last Name:STEFANE
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 1:501 BILLINGSLEY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 BILLINGSLEY RD
Practice Address - Street 2:SUITE B
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1009
Practice Address - Country:US
Practice Address - Phone:704-444-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-009022084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY385297OtherMVP
NY11480866OtherCAQH
NY1445U1OtherBLUE CROSS
NY10100302OtherCDPHP
NC1376500264Medicaid
NY000410257001OtherBLUE SHIELD
SCNC2513Medicaid
NC1376500264Medicaid
NY385297OtherMVP
NY000410257001OtherBLUE SHIELD