Provider Demographics
NPI:1942228259
Name:STEPHAN, KEVIN TODD
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:TODD
Last Name:STEPHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9520 W PALM LN STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-4403
Mailing Address - Country:US
Mailing Address - Phone:623-583-3001
Mailing Address - Fax:623-974-6721
Practice Address - Street 1:13471 W CORNERSTONE BLVD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395
Practice Address - Country:US
Practice Address - Phone:877-809-5092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ56845207R00000X, 207RI0200X
MN45301207RI0200X
IDMC-2536207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ435021Medicaid
MN259393900Medicaid
WI31474500Medicaid