Provider Demographics
NPI:1366478455
Name:STEPHENSON, ANDREW J (MD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:J
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:100 METROPOLITAN PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-7112
Mailing Address - Country:US
Mailing Address - Phone:315-870-9369
Mailing Address - Fax:312-563-3721
Practice Address - Street 1:1226 E WATER ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1155
Practice Address - Country:US
Practice Address - Phone:315-478-4185
Practice Address - Fax:315-478-0840
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2023-11-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301117114208800000X
IAMD-46076208800000X
IN01091812B208800000X
IL036-148679208800000X
OH35086609208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2614424Medicaid
OH2614424Medicaid
OHST7344061Medicare PIN