Provider Demographics
NPI:1811164205
Name:STEVENS, KIRK D (MD)
Entity type:Individual
Prefix:DR
First Name:KIRK
Middle Name:D
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:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58107-2168
Mailing Address - Country:US
Mailing Address - Phone:701-234-2119
Mailing Address - Fax:
Practice Address - Street 1:5225 23RD AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7927
Practice Address - Country:US
Practice Address - Phone:701-417-2575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND11975207L00000X
NDPT 11975207Q00000X
MA239273207Q00000X
NY247216207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND16104Medicaid
MN1811164205Medicaid
NDN716633Medicare Oscar/Certification
ND16104Medicaid
MA110083411AMedicaid
MA001128801Medicare PIN
MA2723003OtherCIGNA
MAAA147810OtherH.P.
MAJ44580OtherBCBSMA