Provider Demographics
NPI:1821018813
Name:STEPHENSON, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629D LOWTHER RD
Mailing Address - Street 2:SUITE 3950
Mailing Address - City:LEWISBERRY
Mailing Address - State:PA
Mailing Address - Zip Code:17339-9527
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:629D LOWTHER RD
Practice Address - Street 2:SUITE 3950
Practice Address - City:LEWISBERRY
Practice Address - State:PA
Practice Address - Zip Code:17339-9527
Practice Address - Country:US
Practice Address - Phone:717-932-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA4311872085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101880263Medicaid
114754Medicare PIN
I57802Medicare UPIN