Provider Demographics
NPI:1417362104
Name:STEVENS, BRIAN ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ALAN
Last Name:STEVENS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7936 N WAYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-5802
Mailing Address - Country:US
Mailing Address - Phone:813-732-9580
Mailing Address - Fax:
Practice Address - Street 1:10180 SE SUNNYSIDE RD
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015
Practice Address - Country:US
Practice Address - Phone:503-571-2880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-22
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021377207P00000X
ORDO186776207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5315066924OtherPHARM
MI5101021377OtherMEDICAL
MI1417362104OtherRESIDENCY