Basic Information
| Provider Information | |||||||||
| NPI: | 1154420990 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SERFONTEIN | ||||||||
| FirstName: | STEPHANUS | ||||||||
| MiddleName: | JOHANNES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 MACCORKLE SEAVE B16 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253041227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043885848 | ||||||||
| FaxNumber: | 3043889654 | ||||||||
| Practice Location | |||||||||
| Address1: | 2418 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | PT PLEASANT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255501528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046756835 | ||||||||
| FaxNumber: | 3046756849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 12/22/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 21778 | WV | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2548390 | 05 | OH | MEDICAID | 3810001774 | 05 | WV | MEDICAID |