MEDICARE: KENNETH STEVENS MD INC A MEDICAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05D1083425	OTHER	CA	CLIA CERTIFICATE OF WAIVER NUMBER
2	ZZZ53712Y	OTHER	CA	BLUE SHIELD PROVIDER NUMBER
3	C3092297	OTHER	CA	DEPT OF CORPORATIONS NUMBER
4	37534	OTHER	CA	MEDICAL BOARD FICTITIOUS NAME PERMIT NUMBER
5	106286	OTHER	CA	CITY OF SAN LUIS OBISPO BUSINESS LICENSE

General Provider Information

NPI Number	:	1265606081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNETH STEVENS MD INC A MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	3268 WATERSTONE AVE
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89044-1867
Country	:	US
Telephone Number	:	815-378-8514
Fax Number	:	805-540-3344

Provider Business Practice Location Address
First Line	:	3268 WATERSTONE AVE
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89044-1867
Country	:	US
Telephone Number	:	815-378-8514
Fax Number	:	805-540-3344

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KENNETH STEVENS
Credential	:	MD
Telephone Number	:	815-378-8514

Provider Enumeration Date	:	04/14/2008
Last Update Date	:	05/05/2025

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