Provider Demographics
NPI:1225033459
Name:MESA, STEPHEN M (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:M
Last Name:MESA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 S CRYSLER AVE
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-5906
Mailing Address - Country:US
Mailing Address - Phone:816-356-0400
Mailing Address - Fax:816-356-0477
Practice Address - Street 1:4419 S CRYSLER AVE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-5906
Practice Address - Country:US
Practice Address - Phone:816-356-0400
Practice Address - Fax:816-356-0477
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR50258207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO240286708Medicaid
MO01240028OtherBLUE CROSS BLUE SHIELD OF KANSAS CITY
MO080019432OtherRAILROAD MEDICARE PALMETTO GBA
MO01240028OtherBLUE CROSS BLUE SHIELD OF KANSAS CITY
MO0003092Medicare PIN