Provider Demographics
NPI:1841213428
Name:STEPHENSON, JOHN (MC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT IGNACE
Mailing Address - State:MI
Mailing Address - Zip Code:49781-1724
Mailing Address - Country:US
Mailing Address - Phone:906-643-7168
Mailing Address - Fax:906-643-0463
Practice Address - Street 1:1140 N STATE ST
Practice Address - Street 2:
Practice Address - City:SAINT IGNACE
Practice Address - State:MI
Practice Address - Zip Code:49781-1048
Practice Address - Country:US
Practice Address - Phone:906-643-0402
Practice Address - Fax:906-643-0463
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028300207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F04716Medicare UPIN
OD96239026Medicare ID - Type Unspecified