Provider Demographics
NPI:1477664415
Name:STEPHENS, POLLY LAURA (MD)
Entity Type:Individual
Prefix:
First Name:POLLY
Middle Name:LAURA
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:POLLY
Other - Middle Name:
Other - Last Name:FATSI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:601 WATKINS CENTRE PARKWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114
Mailing Address - Country:US
Mailing Address - Phone:804-594-3130
Mailing Address - Fax:804-423-6517
Practice Address - Street 1:601 WATKINS CENTRE PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114
Practice Address - Country:US
Practice Address - Phone:804-594-3130
Practice Address - Fax:804-423-6517
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101057448208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010187311Medicaid
VA00W528V15Medicare ID - Type Unspecified
VAG77631Medicare UPIN