Provider Demographics
NPI:1417338401
Name:STEPHENSON, MAXWELL
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:STEPHENSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 EUREKA ROAD
Mailing Address - Street 2:MEDICAL OFFICE BUILDING C, 4TH FLOOR
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2200
Mailing Address - Country:US
Mailing Address - Phone:916-474-6590
Mailing Address - Fax:
Practice Address - Street 1:1600 EUREKA ROAD
Practice Address - Street 2:MEDICAL OFFICE BUILDING C, 4TH FLOOR
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2200
Practice Address - Country:US
Practice Address - Phone:916-474-6590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA157080207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine