Provider Demographics
NPI:1114913522
Name:HARTZELL, STEPHEN WARREN (MD PHD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:WARREN
Last Name:HARTZELL
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:486 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NC
Mailing Address - Zip Code:28721-8026
Mailing Address - Country:US
Mailing Address - Phone:828-452-5816
Mailing Address - Fax:828-452-0373
Practice Address - Street 1:486 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:NC
Practice Address - Zip Code:28721-8026
Practice Address - Country:US
Practice Address - Phone:828-452-5816
Practice Address - Fax:828-452-0373
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900863207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891233JMedicaid
2279383Medicare PIN
H03405Medicare UPIN
NC1177520001Medicare NSC