Provider Demographics
NPI:1114901188
Name:STEVENS, MICHAEL WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:STEVENS
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 1:3075 GOVERNORS PLACE BLVD
Mailing Address - Street 2:STE 110
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-1332
Mailing Address - Country:US
Mailing Address - Phone:937-296-0015
Mailing Address - Fax:937-296-0074
Practice Address - Street 1:3075 GOVERNORS PLACE BLVD
Practice Address - Street 2:STE 110
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-1332
Practice Address - Country:US
Practice Address - Phone:937-296-0015
Practice Address - Fax:937-296-0074
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35060576207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0381831Medicaid
OHST0817222Medicare ID - Type Unspecified
OH0381831Medicaid