Provider Demographics
NPI:1285824748
Name:PROTAS, STEPHEN G (DO)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:G
Last Name:PROTAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7210 N 16TH DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-7926
Mailing Address - Country:US
Mailing Address - Phone:602-570-6856
Mailing Address - Fax:
Practice Address - Street 1:275 E 200 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-2002
Practice Address - Country:US
Practice Address - Phone:800-366-1884
Practice Address - Fax:866-360-6021
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0967207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZD47129Medicare UPIN