Healthcare Provider Details

I. General information

NPI: 1669482329
Provider Name (Legal Business Name): KURT B STEVENSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W. FORT ST. # 111
BOISE ID
83702
US

IV. Provider business mailing address

500 W. FORT ST. # 111
BOISE ID
83702
US

V. Phone/Fax

Practice location:
  • Phone: 208-422-1000
  • Fax: 208-422-1319
Mailing address:
  • Phone: 208-422-1000
  • Fax: 208-422-1319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number35086654
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: