Basic Information
| Provider Information | |||||||||
| NPI: | 1346249315 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUMPHRIES | ||||||||
| FirstName: | STEFAN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3152 LITTLE RD # 162 | ||||||||
| Address2: | |||||||||
| City: | TRINITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346551864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472895727 | ||||||||
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| Practice Location | |||||||||
| Address1: | 301 MEMORIAL MEDICAL PKWY | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321175167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862316000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 03/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 14305 | NV | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 37261 | CO | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 26359 | AZ | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | ME148755 | FL | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 10384750 | 01 | CAQH | OTHER | 22137246 | 05 | CO | MEDICAID | 1346249315 | 05 | NV | MEDICAID |