Provider Demographics
NPI:1457476079
Name:STEVENS, MICHAEL BRUCE (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRUCE
Last Name:STEVENS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4331
Mailing Address - Country:US
Mailing Address - Phone:559-625-8636
Mailing Address - Fax:
Practice Address - Street 1:2820 W MAIN ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-4331
Practice Address - Country:US
Practice Address - Phone:559-625-8636
Practice Address - Fax:559-625-9941
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46338174400000X
CAG0436338208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFO5469Medicare UPIN