Healthcare Provider Details

I. General information

NPI: 1013960301
Provider Name (Legal Business Name): TOMMY SOGBAFAI STEVENS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 01/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2298 S CENTER RD
BURTON MI
48519-1166
US

IV. Provider business mailing address

2298 S CENTER RD
BURTON MI
48519-1166
US

V. Phone/Fax

Practice location:
  • Phone: 810-742-2544
  • Fax: 810-742-2566
Mailing address:
  • Phone: 810-742-2544
  • Fax: 810-742-2566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberTS039213
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTS039213
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: