Basic Information
| Provider Information | |||||||||
| NPI: | 1316979214 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOENNING | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2147 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339022147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393439190 | ||||||||
| FaxNumber: | 2393439193 | ||||||||
| Practice Location | |||||||||
| Address1: | 12550 NEW BRITTANY BLVD STE 201 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393439190 | ||||||||
| FaxNumber: | 2393439193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | ME46778 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 271843000 | 05 | FL | MEDICAID |