Provider Demographics
NPI:1063426724
Name:STAVRAKOS, JOHN EVANS (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EVANS
Last Name:STAVRAKOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1320
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29071-1320
Mailing Address - Country:US
Mailing Address - Phone:803-244-9212
Mailing Address - Fax:
Practice Address - Street 1:103 SUM MOR DR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4828
Practice Address - Country:US
Practice Address - Phone:803-244-9212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39963208100000X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I36957Medicare UPIN