Provider Demographics
NPI:1538237375
Name:RALSTON, STEPHAN L (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHAN
Middle Name:L
Last Name:RALSTON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1452 E RIDGELINE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4946
Mailing Address - Country:US
Mailing Address - Phone:801-479-5937
Mailing Address - Fax:801-479-5917
Practice Address - Street 1:1452 E RIDGELINE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4946
Practice Address - Country:US
Practice Address - Phone:801-479-5937
Practice Address - Fax:801-479-5917
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT1648361205208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTC63405Medicare UPIN