Provider Demographics
NPI:1336248335
Name:STEVENSON, JOHN REGIS (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:REGIS
Last Name:STEVENSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 PLEASANT AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4670
Mailing Address - Country:US
Mailing Address - Phone:937-435-6585
Mailing Address - Fax:937-435-6563
Practice Address - Street 1:8721 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1331
Practice Address - Country:US
Practice Address - Phone:937-264-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002504213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0757739Medicaid
OH0652437Medicare PIN
OH4121631Medicare PIN
OH4121633Medicare PIN
OH0757739Medicaid