Provider Demographics
NPI:1740441443
Name:STEPHENSON, DEREK ALLEN (MD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:ALLEN
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 1:1103 WEST SHERMAN AVENUE
Mailing Address - Street 2:BUILDING 2 UNIT C
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360
Mailing Address - Country:US
Mailing Address - Phone:856-362-5259
Mailing Address - Fax:856-405-6978
Practice Address - Street 1:1103 WEST SHERMAN AVENUE
Practice Address - Street 2:BUILDING 2 UNIT C
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360
Practice Address - Country:US
Practice Address - Phone:856-362-5259
Practice Address - Fax:856-405-6978
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-24
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR70529208600000X
FLME116873390200000X
NJ25MA09618900208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0475025Medicaid