Provider Demographics
NPI:1750332649
Name:STEVENSON, MARK EDWARD (MD, MPH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:STEVENSON
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4729 COUNTY ROAD 101
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-2634
Mailing Address - Country:US
Mailing Address - Phone:952-974-3200
Mailing Address - Fax:
Practice Address - Street 1:4729 COUNTY ROAD 101
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-2634
Practice Address - Country:US
Practice Address - Phone:952-974-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34960207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNE72840Medicare UPIN