Provider Demographics
NPI:1548243785
Name:HARIDOPOLOS, STEPHANIE E (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:E
Last Name:HARIDOPOLOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 BROADBAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901
Mailing Address - Country:US
Mailing Address - Phone:321-733-1901
Mailing Address - Fax:321-733-0211
Practice Address - Street 1:1140 BROADBAND DRIVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:321-255-6670
Practice Address - Fax:321-242-2545
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL080182833OtherRAILROAD MEDICARE
FL7108364OtherAETNA
FL6098787001OtherCIGNA
FL13081OtherBLUE CROSS BLUE SHIELD
FL2897371OtherAETNA
FL2897371OtherAETNA
H58797Medicare UPIN
13081ZMedicare PIN
FL264545900Medicaid