Provider Demographics
NPI:1619975877
Name:VIVIAN, STEPHAN J (MD)
Entity type:Individual
Prefix:
First Name:STEPHAN
Middle Name:J
Last Name:VIVIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7916 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4140
Mailing Address - Country:US
Mailing Address - Phone:260-434-2297
Mailing Address - Fax:260-434-6116
Practice Address - Street 1:500 J CLYDE MORRIS BLVD FL ANNEX1
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1929
Practice Address - Country:US
Practice Address - Phone:757-594-2074
Practice Address - Fax:757-594-3369
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35059262V207RC0000X
IN01081770A207RC0000X
VA0101242715207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1619975877Medicaid
VAP00445778OtherMEDICARE RAILROAD
E58354Medicare UPIN
VAP00445778OtherMEDICARE RAILROAD