Provider Demographics
NPI:1659457232
Name:STAVENS, CHRISTODULOS STEFANATOS (MD)
Entity Type:Individual
Prefix:MR
First Name:CHRISTODULOS
Middle Name:STEFANATOS
Last Name:STAVENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:100 MALLARD CREEK RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4194
Mailing Address - Country:US
Mailing Address - Phone:502-589-7907
Mailing Address - Fax:502-589-1319
Practice Address - Street 1:100 MALLARD CREEK RD
Practice Address - Street 2:SUITE 150
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4194
Practice Address - Country:US
Practice Address - Phone:502-589-7907
Practice Address - Fax:502-589-1319
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01035475A207RC0000X
KY24509207RC0001X, 207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1052057OtherPASSPORT HEALTH PLAN
KY64245095Medicaid
KY000000052133OtherANTHEM BCBS
KY060052924OtherRAILROAD MEDICARE
IN060053877OtherRAILROAD MEDICARE/MADISON
687915OtherFIRST HEALTH
IN200040930Medicaid
KY25-00167OtherUNITED HEALTHCARE
299856OtherFEDERAL BLACK LUNG PROGRA
KY415633POtherSIHO HEALTH PLAN
KY060052921OtherRAILROAL MEDICARE/TVILLE
IN060053877OtherRAILROAD MEDICARE/MADISON
IN084820AMedicare PIN
KY25-00167OtherUNITED HEALTHCARE
KY25-00167OtherUNITED HEALTHCARE
KY0874901Medicare ID - Type UnspecifiedLOUISVILLE
3072OtherCHA PROVIDER NETWORK
0360976002OtherCIGNA
KY060052921OtherRAILROAL MEDICARE/TVILLE
KY00181006Medicare ID - Type UnspecifiedCARROLLTON