Basic Information
| Provider Information | |||||||||
| NPI: | 1063412781 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLETCHER | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 925 NE 30TH TER | ||||||||
| Address2: | # 214 | ||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330337613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052455881 | ||||||||
| FaxNumber: | 7865331680 | ||||||||
| Practice Location | |||||||||
| Address1: | 925 NE 30TH TER | ||||||||
| Address2: | # 214 | ||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330337613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052455881 | ||||||||
| FaxNumber: | 7865331680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
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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 | 207YP0228X | ME46707 | FL | N | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology | 207YS0123X | ME46707 | FL | N | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery | 207YX0007X | ME46707 | FL | N | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck | 207YX0602X | ME46707 | FL | N | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngic Allergy | 207Y00000X | ME46707 | FL | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 048348600 | 05 | FL | MEDICAID |