Provider Demographics
NPI:1992022800
Name:HUDDLESTON, STEPHEN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:HUDDLESTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1432 KIMBROUGH RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2405
Mailing Address - Country:US
Mailing Address - Phone:901-767-4499
Mailing Address - Fax:901-761-0727
Practice Address - Street 1:1432 KIMBROUGH RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-2405
Practice Address - Country:US
Practice Address - Phone:901-767-4499
Practice Address - Fax:901-761-0727
Is Sole Proprietor?:No
Enumeration Date:2010-05-01
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN51045207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR206796001Medicaid
TNQ009896Medicaid
MO1992022800Medicaid
AL1992022800Medicaid
MS00284540Medicaid
GA003181608AMedicaid