Provider Demographics
NPI:1790768778
Name:PIERCE, STEPHEN LEWIS (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LEWIS
Last Name:PIERCE
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:P.O. BOX 1337
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:505-722-1421
Practice Address - Street 1:516 EAST NIZHONI BLVD.
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-1337
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-722-1421
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35051584P207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200176340Medicaid
OH0864417Medicaid
KY64958440Medicaid
000000378393OtherANTHEM BLUE SHIELD
OH0864417Medicaid
000000378393OtherANTHEM BLUE SHIELD
P00330190Medicare PIN