Provider Demographics
NPI:1154420990
Name:SERFONTEIN, STEPHANUS JOHANNES (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANUS
Middle Name:JOHANNES
Last Name:SERFONTEIN
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 1:3200 MACCORKLE SEAVE B16
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1227
Mailing Address - Country:US
Mailing Address - Phone:304-388-5848
Mailing Address - Fax:304-388-9654
Practice Address - Street 1:2418 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:PT PLEASANT
Practice Address - State:WV
Practice Address - Zip Code:25550-1528
Practice Address - Country:US
Practice Address - Phone:304-675-6835
Practice Address - Fax:304-675-6849
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21778207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2548390Medicaid
WV3810001774Medicaid
WV3810001774Medicaid
WV4269112Medicare PIN