Provider Demographics
NPI:1720055999
Name:STEPHENSON, GRANT WILKES (MD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:WILKES
Last Name:STEPHENSON
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:PO BOX 693
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:NY
Mailing Address - Zip Code:14775-0693
Mailing Address - Country:US
Mailing Address - Phone:716-736-6300
Mailing Address - Fax:716-736-6302
Practice Address - Street 1:1 1/2 GOODRICH ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:NY
Practice Address - Zip Code:14775-9546
Practice Address - Country:US
Practice Address - Phone:716-736-6300
Practice Address - Fax:716-736-6302
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170427207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01041730Medicaid
NYB82984Medicare UPIN
NY01041730Medicaid