Healthcare Provider Details

I. General information

NPI: 1659457232
Provider Name (Legal Business Name): CHRISTODULOS STEFANATOS STAVENS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 06/14/2023
Certification Date: 06/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MALLARD CREEK RD SUITE 150
LOUISVILLE KY
40207-4194
US

IV. Provider business mailing address

100 MALLARD CREEK RD SUITE 150
LOUISVILLE KY
40207-4194
US

V. Phone/Fax

Practice location:
  • Phone: 502-589-7907
  • Fax: 502-589-1319
Mailing address:
  • Phone: 502-589-7907
  • Fax: 502-589-1319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number01035475A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number24509
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number24509
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number24509
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: