Provider Demographics
NPI:1790763464
Name:ALTIC, STEPHEN (DO)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:ALTIC
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-2495
Mailing Address - Country:US
Mailing Address - Phone:614-488-7929
Mailing Address - Fax:
Practice Address - Street 1:1550 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-2495
Practice Address - Country:US
Practice Address - Phone:614-488-7929
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34003544207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0536941Medicaid
OHE59720Medicare UPIN
OH0536941Medicaid