Provider Demographics
NPI:1366495178
Name:STEVENS, JONATHAN CRAIG (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:CRAIG
Last Name:STEVENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:J
Other - Middle Name:CRAIG
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 353
Mailing Address - Street 2:
Mailing Address - City:CLARK FORK
Mailing Address - State:ID
Mailing Address - Zip Code:83811
Mailing Address - Country:US
Mailing Address - Phone:208-266-1677
Mailing Address - Fax:208-266-0440
Practice Address - Street 1:105 VERMEER DR UNIT 1
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-9802
Practice Address - Country:US
Practice Address - Phone:208-266-1677
Practice Address - Fax:208-266-0440
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7507208100000X, 204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805192200Medicaid
1139519Medicare ID - Type Unspecified
C61615Medicare UPIN