Healthcare Provider Details

I. General information

NPI: 1184643629
Provider Name (Legal Business Name): KENNETH STEVENS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3268 WATERSTONE AVE
HENDERSON NV
89044-1867
US

IV. Provider business mailing address

3268 WATERSTONE AVE
HENDERSON NV
89044-1867
US

V. Phone/Fax

Practice location:
  • Phone: 815-378-8514
  • Fax:
Mailing address:
  • Phone: 815-378-8514
  • Fax: 805-540-3344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA102905
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License NumberA102905
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: