Basic Information
Provider Information | |||||||||
NPI: | 1629007620 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEPHENS | ||||||||
FirstName: | LEONA | ||||||||
MiddleName: | JEAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 950202 | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402950202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5025889490 | ||||||||
FaxNumber: | 5022725116 | ||||||||
Practice Location | |||||||||
Address1: | 3118 E 10TH ST | ||||||||
Address2: |   | ||||||||
City: | JEFFERSONVILLE | ||||||||
State: | IN | ||||||||
PostalCode: | 471305904 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8122826979 | ||||||||
FaxNumber: | 8122826998 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2006 | ||||||||
LastUpdateDate: | 11/07/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01059486A | IN | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 40465 | KY | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0538679 | 01 |   | MEDICARE NGS--IQ | OTHER | 64129281 | 05 | KY |   | MEDICAID | 0637745 | 01 |   | MEDICARE NGS--PO | OTHER | 0795618 | 01 |   | MEDICARE NGS--ZE | OTHER | 0538494 | 01 |   | MEDICARE NGS--EB | OTHER | 0538577 | 01 |   | MEDICARE NGS--FD | OTHER | 0538778 | 01 |   | MEDICARE NGS--PX | OTHER | 200493190 | 05 | IN |   | MEDICAID |