Provider Demographics
NPI:1144457789
Name:BRESSON, STEPHEN LEE EDWARD (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LEE EDWARD
Last Name:BRESSON
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 1:10140 CENTURION PKWY N FL PROVIDER
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:904-697-4100
Mailing Address - Fax:904-697-5102
Practice Address - Street 1:807 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8426
Practice Address - Country:US
Practice Address - Phone:904-697-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN528612085R0202X
FLME1369472085R0202X
DEC1-00127382085P0229X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1534531Medicaid
FL100228500Medicaid
GA003160798CMedicaid