Provider Demographics
NPI:1174902498
Name:HARYADI, STEPHANUS ERIC (MD)
Entity type:Individual
Prefix:
First Name:STEPHANUS
Middle Name:ERIC
Last Name:HARYADI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8055 MAYFIELD RD STE 105
Mailing Address - Street 2:
Mailing Address - City:CHESTERLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44026-2447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ORWELL
Practice Address - State:OH
Practice Address - Zip Code:44076-9590
Practice Address - Country:US
Practice Address - Phone:440-437-6222
Practice Address - Fax:440-437-1022
Is Sole Proprietor?:No
Enumeration Date:2015-05-19
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.135310207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program