Healthcare Provider Details

I. General information

NPI: 1134145105
Provider Name (Legal Business Name): MARK A STEVENS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 SOLOMIA DR
MILLS RIVER NC
28759-0068
US

IV. Provider business mailing address

1309 COFFEEN AVE STE 1200
SHERIDAN WY
82801-5777
US

V. Phone/Fax

Practice location:
  • Phone: 603-724-1954
  • Fax:
Mailing address:
  • Phone: 603-724-1954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0015X
TaxonomyPsychosomatic Medicine Physician
License Number2019-02734
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number2019-02734
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number2019-02734
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2019-02734
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: