Basic Information
| Provider Information | |||||||||
| NPI: | 1205804424 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEPHENS | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | KELLOGG | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STEPHENS | ||||||||
| OtherFirstName: | G | ||||||||
| OtherMiddleName: | KELLY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | III | ||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4345 W MEMORIAL RD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731341702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059365800 | ||||||||
| FaxNumber: | 4059365211 | ||||||||
| Practice Location | |||||||||
| Address1: | 2017 W I 35 FRONTAGE RD | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730138504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057573365 | ||||||||
| FaxNumber: | 4057573498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 08/14/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 15338 | OK | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 100128790B | 05 | OK | MEDICAID |