Basic Information
| Provider Information | |||||||||
| NPI: | 1306841937 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEPHANS | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | EUGENE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 743409 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303743409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275320002 | ||||||||
| FaxNumber: | 7275321325 | ||||||||
| Practice Location | |||||||||
| Address1: | 4211 VAN DYKE RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LUTZ | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335588005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139604026 | ||||||||
| FaxNumber: | 8139604489 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME48077 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 264682000 | 05 | FL | MEDICAID |