Provider Demographics
NPI:1487195756
Name:PACKER, STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:PACKER
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 1:3500 POSNER BLVD # 1277
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33837-3640
Mailing Address - Country:US
Mailing Address - Phone:725-222-0807
Mailing Address - Fax:707-666-6480
Practice Address - Street 1:2527 WILDBROOK AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89086-1548
Practice Address - Country:US
Practice Address - Phone:725-222-0807
Practice Address - Fax:707-666-6480
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-20
Last Update Date:2023-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV22027207L00000X, 207L00000X
FLME147091207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA87013OtherMEDICAL BOARD
FLME147091OtherMEDICAL BOARD
TN62203OtherMEDICAL BOARD
NV22027OtherMEDICAL BOARD