Healthcare Provider Details

I. General information

NPI: 1144307612
Provider Name (Legal Business Name): DENNIS LEROY STEVENS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W FORT ST
BOISE ID
83702-4501
US

IV. Provider business mailing address

4461 E VICTORY RD
MERIDIAN ID
83642-7011
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1000
  • Fax:
Mailing address:
  • Phone: 208-362-7144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberM-5648
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: