Basic Information
| Provider Information | |||||||||
| NPI: | 1942302799 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EUBANKS | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 SOUTHHALL LN STE 300 | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4078752080 | ||||||||
| FaxNumber: | 4076503455 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 DUNLAWTON AVE STE 2 | ||||||||
| Address2: | |||||||||
| City: | PORT ORANGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321272916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3863228310 | ||||||||
| FaxNumber: | 3863228370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 207N00000X | 23922 | CO | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | ME133377 | FL | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 01239227 | 05 | CO | MEDICAID | 070014537 | 01 | CO | RR MEDICARE | OTHER | 30757 | 01 | CO | BCBS | OTHER | 84-1511239 | 01 | CO | OTHER | OTHER |