Provider Demographics
NPI:1245215607
Name:FRESHWATER, STEPHEN JOHN (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JOHN
Last Name:FRESHWATER
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 1:906 NORTH MAIN STREET
Mailing Address - Street 2:P.O. BOX 319
Mailing Address - City:ARLINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45814-0319
Mailing Address - Country:US
Mailing Address - Phone:419-365-5153
Mailing Address - Fax:419-365-0081
Practice Address - Street 1:906 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:OH
Practice Address - Zip Code:45814-0319
Practice Address - Country:US
Practice Address - Phone:419-365-5153
Practice Address - Fax:419-365-0081
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-052289207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHFR 0597792OtherMEDICARE ID
OH0660575Medicaid
OH080011518Medicare PIN
OHA16868Medicare UPIN