Provider Demographics
NPI:1932138195
Name:STEPHANZ, GERALD B (MD)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:B
Last Name:STEPHANZ
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 1:1055 N 500 W
Mailing Address - Street 2:CREDENTIALING DEPARTMENT
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-429-8180
Practice Address - Street 1:1055 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3305
Practice Address - Country:US
Practice Address - Phone:801-377-4623
Practice Address - Fax:801-377-6832
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2743691205207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT124890OtherDMBA
UT31-0041OtherUNITED HEALTHCARE
UT870281028ST2OtherEMIA
UT870281028000Medicaid
UTQM0000044589OtherALTIUS
UT107006986101OtherIHC
UT62051OtherPEHP
UT870281028ST2OtherEMIA