Provider Demographics
NPI:1730106410
Name:STEPHANIAN, ERICK (MD)
Entity Type:Individual
Prefix:DR
First Name:ERICK
Middle Name:
Last Name:STEPHANIAN
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 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3750 LANDMARK DR STE B
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-6652
Practice Address - Country:US
Practice Address - Phone:765-448-4100
Practice Address - Fax:765-448-7610
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73185207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400031681Medicare PIN
IN149410Medicare PIN
IN000000112107OtherANTHEM
INF80803Medicare UPIN
IN100380830BMedicaid