Provider Demographics
NPI:1255531653
Name:STEFAN, MARIO (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:STEFAN
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 1:17914 LAKE AZURE WAY
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-1048
Mailing Address - Country:US
Mailing Address - Phone:561-843-3852
Mailing Address - Fax:
Practice Address - Street 1:17914 LAKE AZURE WAY
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33496-1048
Practice Address - Country:US
Practice Address - Phone:561-843-3852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82693207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine