Provider Demographics
NPI:1134569882
Name:STEVENS, KENNETH R III
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:STEVENS
Suffix:III
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 1:3850 DOVE ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2912
Mailing Address - Country:US
Mailing Address - Phone:503-998-0614
Mailing Address - Fax:
Practice Address - Street 1:4077 FIFTH AVE # MER35
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103
Practice Address - Country:US
Practice Address - Phone:503-998-0614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA148746207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program