Provider Demographics
NPI:1992018378
Name:STEPANIAN, NICOLA (DO)
Entity Type:Individual
Prefix:
First Name:NICOLA
Middle Name:
Last Name:STEPANIAN
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 1:4453 CASTOR AVE
Mailing Address - Street 2:STE B
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-3846
Mailing Address - Country:US
Mailing Address - Phone:215-744-2266
Mailing Address - Fax:215-743-9247
Practice Address - Street 1:4453 CASTOR AVE
Practice Address - Street 2:STE B
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-3846
Practice Address - Country:US
Practice Address - Phone:215-744-2266
Practice Address - Fax:215-743-9247
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS015570207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA037276OtherMLHC MEDICARE AA #
PA232359401OtherMLHC TIN