Basic Information
| Provider Information | |||||||||
| NPI: | 1578550794 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEPHAN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 53134 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705053134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372615151 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2311 KALISTE SALOOM RD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705086807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3372615151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 10/26/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 16703 | LA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00139272 | 01 | LA | RAILROAD MEDICARE | OTHER | 1389552 | 05 | LA | MEDICAID |