Provider Demographics
NPI:1508850496
Name:STEPHENSON, STEPHEN R (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:STEPHENSON
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 1:1215 PLEASANT ST.
Mailing Address - Street 2:STE. 306
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1453
Mailing Address - Country:US
Mailing Address - Phone:515-241-5926
Mailing Address - Fax:515-241-5127
Practice Address - Street 1:1215 PLEASANT ST.
Practice Address - Street 2:STE. 306
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1453
Practice Address - Country:US
Practice Address - Phone:515-241-5926
Practice Address - Fax:515-241-5127
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA351872080P0207X
CAG316072080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1508850496Medicaid
175150045OtherMEDICARE
175150045OtherMEDICARE