Provider Demographics
NPI:1518462639
Name:CASELLA, STEPHANIE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CASELLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 W BALDWIN RD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-3313
Mailing Address - Country:US
Mailing Address - Phone:850-522-1522
Mailing Address - Fax:850-522-5925
Practice Address - Street 1:528 W BALDWIN RD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-3313
Practice Address - Country:US
Practice Address - Phone:850-522-1522
Practice Address - Fax:850-522-5925
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXU98642080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113954700Medicaid