Provider Demographics
NPI:1033205448
Name:STEVENS, ISHMAEL WORTH JR (MD)
Entity Type:Individual
Prefix:
First Name:ISHMAEL
Middle Name:WORTH
Last Name:STEVENS
Suffix:JR
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 1:700 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101
Mailing Address - Country:US
Mailing Address - Phone:606-329-0204
Mailing Address - Fax:606-324-7770
Practice Address - Street 1:700 13TH ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101
Practice Address - Country:US
Practice Address - Phone:606-329-0204
Practice Address - Fax:606-324-7770
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35295208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65917544Medicaid
KY000000111530OtherANTHEM BC
KY64012503Medicaid
WV6700603-000Medicaid
KY1200987OtherUNITED HEALTH CARE
KY336109752062214OtherBC SUPER BLUE PLUS