Provider Demographics
NPI:1093787541
Name:STEPHENSON, WILLIAM T II (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:T
Last Name:STEPHENSON
Suffix:II
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 1:1121 E 3900 S STE C230
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1297
Mailing Address - Country:US
Mailing Address - Phone:801-262-9494
Mailing Address - Fax:866-415-6807
Practice Address - Street 1:395 W BULLDOG BLVD STE 103
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3334
Practice Address - Country:US
Practice Address - Phone:801-357-8200
Practice Address - Fax:801-357-8201
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT274407-1205207RH0000X, 207RX0202X
MO108812207RH0003X
KS04-25846207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204885701Medicaid
MO1093787541Medicaid
KS100361590BMedicaid
KS100361590CMedicaid
KS100361590 DMedicaid
MOP00688343Medicare PIN
MO5657741EMedicare PIN
MOP00729466Medicare PIN
KSP00729479Medicare UPIN
MOF19715Medicare UPIN
KS100361590CMedicaid
KS100361590BMedicaid
MOMA1794004Medicare PIN