Provider Demographics
NPI:1629259049
Name:CALLIS, STEPHEN B (LMT)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:B
Last Name:CALLIS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3145
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-2045
Mailing Address - Country:US
Mailing Address - Phone:860-966-8204
Mailing Address - Fax:860-896-1383
Practice Address - Street 1:16 JANET LN
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-3512
Practice Address - Country:US
Practice Address - Phone:860-966-8204
Practice Address - Fax:860-896-1383
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004705175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath