1033116975 NPI number — DR. GREGORY J. STELLA M.D.

Table of content: MICHELLE BROZO COLL M.S.,CCC/A (NPI 1457668980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033116975 NPI number — DR. GREGORY J. STELLA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STELLA
Provider First Name:
GREGORY
Provider Middle Name:
J.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033116975
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/21/2006
NPI Reactivation Date:
03/28/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4800 BELFORT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32256-6004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-398-3262
Provider Business Mailing Address Fax Number:
904-265-4807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3635 S CLYDE MORRIS BLVD
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
PORT ORANGE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32129-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-788-1242
Provider Business Practice Location Address Fax Number:
386-788-4255
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  ME44104 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 270347500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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