Provider Demographics
NPI:1821034422
Name:ENSELEIT, STEPHEN MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:ENSELEIT
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 1:3131 NEWMARK DR STE 220
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-5400
Mailing Address - Country:US
Mailing Address - Phone:937-438-8910
Mailing Address - Fax:937-436-4984
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-395-8166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35087933146D00000X
OH35-087933207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2662677Medicaid
OH000000476045OtherANTHEM BC/BS
OH2662677Medicaid
OH4184172Medicare PIN