Provider Demographics
NPI:1093821019
Name:SHAVER, STEFANIE LEE (MD)
Entity type:Individual
Prefix:DR
First Name:STEFANIE
Middle Name:LEE
Last Name:SHAVER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 INDEPENDENCE DRIVE KORITZ CLINIC
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39710-7594
Mailing Address - Country:US
Mailing Address - Phone:404-432-2724
Mailing Address - Fax:
Practice Address - Street 1:KORITZ CLINIC 201 INDEPENDENCE DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39710-7139
Practice Address - Country:US
Practice Address - Phone:662-434-2292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056647207Q00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA802792298BMedicaid