Provider Demographics
NPI:1639136229
Name:STEPHENSON, SHELBY A (MD)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:A
Last Name:STEPHENSON
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:PO BOX 64363
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-0363
Mailing Address - Country:US
Mailing Address - Phone:910-483-3534
Mailing Address - Fax:
Practice Address - Street 1:1629 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3425
Practice Address - Country:US
Practice Address - Phone:910-484-2284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24950207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC180018924OtherRAILROAD MEDICARE
NC8979732Medicaid
NC8979731Medicaid
NC202412Medicare ID - Type UnspecifiedFAYETTEVILLE OFFICE
NC0750960001Medicare NSC
NC8979732Medicaid