Basic Information
| Provider Information | |||||||||
| NPI: | 1942228259 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEPHAN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | TODD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9520 W PALM LN STE 200 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850374403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235833001 | ||||||||
| FaxNumber: | 6239746721 | ||||||||
| Practice Location | |||||||||
| Address1: | 13471 W CORNERSTONE BLVD | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778095092 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 11/13/2018 | ||||||||
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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 | 207RI0200X | 45301 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207RI0200X | 56845 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 207R00000X | 56845 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 259393900 | 05 | MN | MEDICAID | 31474500 | 05 | WI | MEDICAID | 435021 | 05 | AZ | MEDICAID |