Healthcare Provider Details

I. General information

NPI: 1366736886
Provider Name (Legal Business Name): PAUL STEVENS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2011
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 S KOMAS DR STE 200
SALT LAKE CITY UT
84108-1241
US

IV. Provider business mailing address

650 S KOMAS DR STE 200
SALT LAKE CITY UT
84108-1241
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-5515
  • Fax: 801-581-8979
Mailing address:
  • Phone: 801-581-5515
  • Fax: 801-581-8979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number361354-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: