Provider Demographics
NPI:1245267715
Name:STEVENSON, STEPHEN E (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:E
Last Name:STEVENSON
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 1:11400 158TH RD
Mailing Address - Street 2:
Mailing Address - City:MAYETTA
Mailing Address - State:KS
Mailing Address - Zip Code:66509-8866
Mailing Address - Country:US
Mailing Address - Phone:785-966-8200
Mailing Address - Fax:785-966-8200
Practice Address - Street 1:11400 158TH RD
Practice Address - Street 2:
Practice Address - City:MAYETTA
Practice Address - State:KS
Practice Address - Zip Code:66509-8866
Practice Address - Country:US
Practice Address - Phone:785-966-8200
Practice Address - Fax:785-966-8200
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-22751207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS04-22751OtherKS ST BOARD OF HEALING AR
CO38375OtherSTATE OF COLORADO
KS17D0668588OtherCLIA CERTIFICATE
KS200259300AMedicaid
KS200259300AMedicaid
CO38375OtherSTATE OF COLORADO
KS103523Medicare ID - Type Unspecified