Provider Demographics
NPI:1376647024
Name:ROMAGNOLO, STEPHEN CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:CHARLES
Last Name:ROMAGNOLO
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 1:6824 SUWANNEE PLAZA LN
Mailing Address - Street 2:PMB 173
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-7495
Mailing Address - Country:US
Mailing Address - Phone:813-416-7888
Mailing Address - Fax:
Practice Address - Street 1:6824 SUWANNEE PLAZA LN
Practice Address - Street 2:PMB 173
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32060-7495
Practice Address - Country:US
Practice Address - Phone:813-416-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91099207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271046300Medicaid
FL49334YMedicare ID - Type Unspecified
FL271046300Medicaid