Provider Demographics
NPI:1184643629
Name:STEVENS, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:STEVENS
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 1:3231 S HIGUERA ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6924
Mailing Address - Country:US
Mailing Address - Phone:805-540-3333
Mailing Address - Fax:805-540-3344
Practice Address - Street 1:3231 S HIGUERA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6924
Practice Address - Country:US
Practice Address - Phone:805-540-3333
Practice Address - Fax:805-540-3344
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA102905202K00000X, 207RI0011X, 207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A1029050OtherBLUE SHIELD PROVIDER NUMBER
CA9136184OtherAETNA PROVIDER NUMBER
CAA102905OtherMEDICAL BOARD LICENSE
CAP00874380Medicare PIN
CAAV516Medicare PIN
CADP161Medicare PIN