Provider Demographics
NPI:1396779781
Name:STIVELY, JOHN EWING III (JOHN STIVELY)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EWING
Last Name:STIVELY
Suffix:III
Gender:M
Credentials:JOHN STIVELY
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:OWENS-STIVELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:JOHN STIVELY
Mailing Address - Street 1:57 BARNES ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-1501
Mailing Address - Country:US
Mailing Address - Phone:401-439-4950
Mailing Address - Fax:
Practice Address - Street 1:200 MILL RD
Practice Address - Street 2:
Practice Address - City:FAIRHAVEN
Practice Address - State:MA
Practice Address - Zip Code:02719-5252
Practice Address - Country:US
Practice Address - Phone:508-999-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA59251207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine