Provider Demographics
NPI:1942820519
Name:FUSELLI, STEPHEN ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ANTHONY
Last Name:FUSELLI
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 1:4810 CLARK LN APT 102
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-9970
Mailing Address - Country:US
Mailing Address - Phone:256-453-5056
Mailing Address - Fax:
Practice Address - Street 1:619 N PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-4355
Practice Address - Country:US
Practice Address - Phone:573-234-1070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020009917261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care