Provider Demographics
NPI:1760469407
Name:DIVERS, STEPHEN G (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:G
Last Name:DIVERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 749495
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9495
Mailing Address - Country:US
Mailing Address - Phone:239-432-8331
Mailing Address - Fax:813-321-1296
Practice Address - Street 1:133 HARMONY PARK
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-5417
Practice Address - Country:US
Practice Address - Phone:501-624-7700
Practice Address - Fax:501-623-5788
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4010207RX0202X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR154309001Medicaid
P00115171OtherRAILROAD MEDICARE
AR5M829Medicare ID - Type Unspecified
AR0752190001Medicare NSC
P00115171OtherRAILROAD MEDICARE