Provider Demographics
NPI:1821013103
Name:STEVENS, DARRYL R (DO)
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:R
Last Name:STEVENS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 TAYLOR AVE STE 140
Mailing Address - Street 2:LAKESHORE IMAGING CONSULTANTS, PLC
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2281
Mailing Address - Country:US
Mailing Address - Phone:231-725-8119
Mailing Address - Fax:616-846-1222
Practice Address - Street 1:1500 E SHERMAN BLVD
Practice Address - Street 2:MERCY GENERAL HEALTH PARTNERS - RADIOLOGY DEPT.
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1849
Practice Address - Country:US
Practice Address - Phone:231-739-9341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDS006137OtherLICENSE
MI2747686Medicaid
MI2747686Medicaid