Provider Demographics
NPI:1336180355
Name:STEVENS, JOHN K (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:K
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 1:2835 BRANDYWINE RD
Mailing Address - Street 2:#300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30341
Mailing Address - Country:US
Mailing Address - Phone:404-256-2593
Mailing Address - Fax:678-547-1494
Practice Address - Street 1:355 TOWER RD NE STE 204
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-9413
Practice Address - Country:US
Practice Address - Phone:404-256-2593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0456332080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00542022AMedicaid
GA00542022AMedicaid
06BDCPNMedicare ID - Type Unspecified