Provider Demographics
NPI:1689730723
Name:STEPHAN, MARK DOUGLAS (RN)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:DOUGLAS
Last Name:STEPHAN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5975 WESTON WOODS DR
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:OH
Mailing Address - Zip Code:43119-8354
Mailing Address - Country:US
Mailing Address - Phone:614-870-8898
Mailing Address - Fax:614-870-8898
Practice Address - Street 1:3563 EDLER ST
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026-1812
Practice Address - Country:US
Practice Address - Phone:614-777-5115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN 185090163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2137182OtherIP NUMBER