Provider Demographics
NPI:1366617078
Name:STEPHENSON, JEFFREY STUART (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:STUART
Last Name:STEPHENSON
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-272-5063
Mailing Address - Fax:
Practice Address - Street 1:9880 ANGIES WAY
Practice Address - Street 2:250
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2851
Practice Address - Country:US
Practice Address - Phone:502-394-6341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY45055207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY767416OtherANTHEM- NORTON MEDICAL ASSOCIATES
KYK043290OtherMEDICARE- NMA OBC
IN201221810Medicaid
KY50039136OtherPASSPORT HEALTH- NMA OBC
KY6222460OtherCIGNA- NORTON MEDICAL ASSOCIATES
KY7100203090Medicaid