Provider Demographics
NPI:1215909379
Name:VANCE, STEPHEN GLENN (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:GLENN
Last Name:VANCE
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 390
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-0390
Mailing Address - Country:US
Mailing Address - Phone:860-271-4700
Mailing Address - Fax:860-271-4797
Practice Address - Street 1:21 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4906
Practice Address - Country:US
Practice Address - Phone:860-439-6400
Practice Address - Fax:860-271-4797
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0517232084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200821230Medicaid
KY64076672Medicaid
IN200821230Medicaid
CTD400086468Medicare PIN
KY0878421Medicare PIN
KY64076672Medicaid