Provider Demographics
NPI:1184643629
Name:STEVENS, KENNETH (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:STEVENS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3268 WATERSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89044-1867
Mailing Address - Country:US
Mailing Address - Phone:815-378-8514
Mailing Address - Fax:805-540-3344
Practice Address - Street 1:3268 WATERSTONE AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89044-1867
Practice Address - Country:US
Practice Address - Phone:815-378-8514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA102905202K00000X, 207RC0000X, 207RC0000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA102905OtherMEDICAL BOARD LICENSE
CA9136184OtherAETNA PROVIDER NUMBER
CA0A1029050OtherBLUE SHIELD PROVIDER NUMBER
CAP00874380Medicare PIN
CAAV516Medicare PIN
CADP161Medicare PIN