Provider Demographics
NPI:1679501753
Name:FANGMAN, STEPHANIE J (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:J
Last Name:FANGMAN
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 1:1120 N. MARR ROAD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-5501
Mailing Address - Country:US
Mailing Address - Phone:812-376-9219
Mailing Address - Fax:812-378-4821
Practice Address - Street 1:1120 N MARR RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5505
Practice Address - Country:US
Practice Address - Phone:812-376-9219
Practice Address - Fax:812-378-4821
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1030306208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100358650Medicaid
000000984524OtherANTHEM PIN