Provider Demographics
NPI:1619902707
Name:STEM, JESSE L (MD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:L
Last Name:STEM
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 1:8009 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33707-2710
Mailing Address - Country:US
Mailing Address - Phone:434-221-9922
Mailing Address - Fax:
Practice Address - Street 1:1609 PASADENA AVE S STE 1A1
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:FL
Practice Address - Zip Code:33707-4565
Practice Address - Country:US
Practice Address - Phone:727-490-9115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101230890207X00000X, 207XS0117X
FLME161780207XS0117X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010160952Medicaid
VA1619902707Medicaid
VAP00220195OtherMEDICARE RAILROAD PIN
007483T88Medicare PIN
P01584711Medicare PIN
VAP00220195OtherMEDICARE RAILROAD PIN
VA1619902707Medicaid