Provider Demographics
NPI:1699717579
Name:JOLLEY, STEPHEN G (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:G
Last Name:JOLLEY
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 1:271 UPPER ROSIAN DR
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7867
Mailing Address - Country:US
Mailing Address - Phone:907-382-4480
Mailing Address - Fax:
Practice Address - Street 1:271 UPPER ROSIAN DR
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7867
Practice Address - Country:US
Practice Address - Phone:907-382-4480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK19562086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD5279Medicaid
AKC96192Medicare UPIN