Provider Demographics
NPI:1013960301
Name:STEVENS, TOMMY SOGBAFAI (MD)
Entity type:Individual
Prefix:MR
First Name:TOMMY
Middle Name:SOGBAFAI
Last Name:STEVENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2298 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1166
Mailing Address - Country:US
Mailing Address - Phone:810-742-2544
Mailing Address - Fax:810-742-2566
Practice Address - Street 1:2298 S CENTER RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48519-1166
Practice Address - Country:US
Practice Address - Phone:810-742-2544
Practice Address - Fax:810-742-2566
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITS039213103TF0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4328356Medicaid
MI0N33340Medicare ID - Type Unspecified
MIA78452Medicare UPIN