Provider Demographics
NPI:1457355398
Name:STEPHENSON, GORDON LESLIE JR (DC)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:LESLIE
Last Name:STEPHENSON
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 MANCHESTER EXPY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-6748
Mailing Address - Country:US
Mailing Address - Phone:706-596-0909
Mailing Address - Fax:706-596-0919
Practice Address - Street 1:1714 MANCHESTER EXPY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6748
Practice Address - Country:US
Practice Address - Phone:706-596-0909
Practice Address - Fax:706-596-0919
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0005828111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35XCGNHMedicare ID - Type UnspecifiedMEDICARE PROVIDER IDENTIF
GAU68577Medicare UPIN