Provider Demographics
NPI:1942219621
Name:STEPHENSON, SEAN RAYL (DO)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:RAYL
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 N LEROY ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2729
Mailing Address - Country:US
Mailing Address - Phone:810-629-0336
Mailing Address - Fax:810-629-7251
Practice Address - Street 1:305 N LEROY ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2729
Practice Address - Country:US
Practice Address - Phone:810-629-0336
Practice Address - Fax:810-629-7251
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016669208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114917050Medicaid
MI114917041Medicaid
MI114917097Medicaid
MI114917041Medicaid
MI114917050Medicaid
MI0P31190009Medicare PIN