Provider Demographics
NPI:1881811412
Name:STEPHENS, MARK WILLIAM (DPM)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 SPAULDING AVE
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-5841
Mailing Address - Country:US
Mailing Address - Phone:609-242-0401
Mailing Address - Fax:
Practice Address - Street 1:102 E BAY AVE
Practice Address - Street 2:SUITE G
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-3175
Practice Address - Country:US
Practice Address - Phone:609-978-2950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00225100213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU22900Medicare UPIN
NJ694837Medicare ID - Type Unspecified