Provider Demographics
NPI:1962470476
Name:STEPHENS, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4410 106TH ST SW
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-4700
Practice Address - Country:US
Practice Address - Phone:425-493-6002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA22184208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
001200726Medicare PIN
G51629Medicare UPIN