Provider Demographics
NPI:1821046244
Name:STEPHENS, KEVIN WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:WAYNE
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1018 N MOUND ST STE 101
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75961-4434
Mailing Address - Country:US
Mailing Address - Phone:365-604-4259
Mailing Address - Fax:936-560-4219
Practice Address - Street 1:1018 N MOUND ST STE 101
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4434
Practice Address - Country:US
Practice Address - Phone:365-604-4259
Practice Address - Fax:936-560-4219
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD21691207Q00000X
TXP2539207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine