Provider Demographics
NPI:1568587293
Name:STEVENS, KENT A (MD)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:A
Last Name:STEVENS
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 1:2401 W BELVEDERE AVE
Mailing Address - Street 2:DEPT. OF CREDENTIALING
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5216
Mailing Address - Country:US
Mailing Address - Phone:410-601-5524
Mailing Address - Fax:410-601-8946
Practice Address - Street 1:2435 W BELVEDERE AVE
Practice Address - Street 2:SUITE 42
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5224
Practice Address - Country:US
Practice Address - Phone:410-601-5547
Practice Address - Fax:410-601-5835
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD65426208600000X, 2086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP00464112OtherMEDICARE R/R PROVIDER #
MDCC1923OtherMEDICARE R/R GROUP #