Provider Demographics
NPI:1265606081
Name:KENNETH STEVENS MD INC A MEDICAL CORPORATION
Entity type:Organization
Organization Name:KENNETH STEVENS MD INC A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-378-8514
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:805-540-3344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D1083425OtherCLIA CERTIFICATE OF WAIVER NUMBER
CAZZZ53712YOtherBLUE SHIELD PROVIDER NUMBER
CAC3092297OtherDEPT OF CORPORATIONS NUMBER
CA37534OtherMEDICAL BOARD FICTITIOUS NAME PERMIT NUMBER
CA106286OtherCITY OF SAN LUIS OBISPO BUSINESS LICENSE
CA106286OtherCITY OF SAN LUIS OBISPO BUSINESS LICENSE
CAZZZ53712YOtherBLUE SHIELD PROVIDER NUMBER