Provider Demographics
NPI:1689784548
Name:STEVENS, DAVID J (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:637 S. WALKER STREET
Practice Address - Street 2:SUITE 2
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2175
Practice Address - Country:US
Practice Address - Phone:812-332-1977
Practice Address - Fax:812-332-1981
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0516207R00000X
IN01069799A207RR0500X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000728700OtherANTHEM PIN
IN201035800Medicaid
INP01105073Medicare PIN
INM400056078Medicare PIN