Provider Demographics
NPI:1881755726
Name:STEPHENSON, ROBERTA SUE (MD)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:SUE
Last Name:STEPHENSON
Suffix:
Gender:F
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 5098
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98415-0098
Mailing Address - Country:US
Mailing Address - Phone:253-272-1812
Mailing Address - Fax:253-682-1455
Practice Address - Street 1:1901 S CEDAR ST STE 103
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2302
Practice Address - Country:US
Practice Address - Phone:253-272-1812
Practice Address - Fax:253-682-1455
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000341442080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8196362Medicaid
WAST8122OtherREGENCE BLUE CROSS SHIELD
WA5206592OtherAETNA