Basic Information
| Provider Information | |||||||||
| NPI: | 1215926274 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLVIN | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 E SOUTHERN AVE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852045045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805458119 | ||||||||
| FaxNumber: | 4809268332 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 E SOUTHERN AVE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852045045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805458119 | ||||||||
| FaxNumber: | 4809268332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 02/14/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 27762 | AZ | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 82680 | 01 | AZ | JRL | OTHER | Z142685 | 01 | MEDICCARE PTAN - ARL | OTHER | 574857 | 05 | AZ | MEDICAID | Z142686 | 01 | AZ | MEDICARE PTAN - EVDI | OTHER | 1215926274 | 01 | AZ | BCBSAZ | OTHER | 1Z7135 | 01 | AZ | HEALTH NET | OTHER |