Provider Demographics
NPI:1740323385
Name:PEARL, STEPHEN K (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:K
Last Name:PEARL
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 1:19 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-2203
Mailing Address - Country:US
Mailing Address - Phone:716-652-0012
Mailing Address - Fax:
Practice Address - Street 1:19 CENTER ST
Practice Address - Street 2:
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-2203
Practice Address - Country:US
Practice Address - Phone:716-652-0012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149605207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P010149605OtherBLUE CHOICE LEGACY#
NYC20354Medicare UPIN