Provider Demographics
NPI:1457312258
Name:STEPHENS, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:STEPHENS
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:PO BOX 708850
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-8850
Mailing Address - Country:US
Mailing Address - Phone:866-869-2397
Mailing Address - Fax:801-352-9502
Practice Address - Street 1:2700 SE STRATUS AVE
Practice Address - Street 2:SUITE 403
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6255
Practice Address - Country:US
Practice Address - Phone:503-435-6441
Practice Address - Fax:503-435-6445
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11580207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR236554Medicaid
ORR130848Medicare ID - Type Unspecified
OR236554Medicaid