Provider Demographics
NPI:1023450533
Name:STEPHENSON, RODERICK WAYNE JR
Entity type:Individual
Prefix:
First Name:RODERICK
Middle Name:WAYNE
Last Name:STEPHENSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4806 5L WESTWOOD PARK DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71109-6257
Mailing Address - Country:US
Mailing Address - Phone:318-636-4444
Mailing Address - Fax:318-636-4444
Practice Address - Street 1:4806 5L WESTWOOD PARK DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71109-6257
Practice Address - Country:US
Practice Address - Phone:318-636-4444
Practice Address - Fax:318-636-4444
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-25
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA008889044343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)