Provider Demographics
NPI:1740461011
Name:DEXTER, STEPHEN E (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:E
Last Name:DEXTER
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 1:2000 BROOKSIDE DR
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4627
Mailing Address - Country:US
Mailing Address - Phone:423-857-5905
Mailing Address - Fax:423-857-5904
Practice Address - Street 1:2000 BROOKSIDE DR
Practice Address - Street 2:3RD FLOOR
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4627
Practice Address - Country:US
Practice Address - Phone:423-857-5905
Practice Address - Fax:423-857-5904
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101245845207R00000X
TN45849207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1517987Medicaid
P00888006OtherRAILROAD MEDICARE
KYJESSE1964Medicaid
VA1740461011Medicaid
P00888006OtherRAILROAD MEDICARE
VAVV7827AMedicare PIN