Provider Demographics
NPI:1679659973
Name:ALCORN, STEPHEN WELLS (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:WELLS
Last Name:ALCORN
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 1:12109 CR 103
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:FL
Mailing Address - Zip Code:34484-2967
Mailing Address - Country:US
Mailing Address - Phone:352-391-6494
Mailing Address - Fax:352-391-6498
Practice Address - Street 1:10192 N NATCHEZ LOOP
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34434-3747
Practice Address - Country:US
Practice Address - Phone:352-522-0225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-29
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME25975208800000X
SD5032208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065337300Medicaid
FL09022OtherBCBS
D52002Medicare UPIN
FL065337300Medicaid