MEDICARE: KENNETH STEVENS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	202K00000X	Phlebology Physician	A102905	CA
2	207RC0000X	Cardiovascular Disease Physician	A102905	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A102905	OTHER	CA	MEDICAL BOARD LICENSE
2	9136184	OTHER	CA	AETNA PROVIDER NUMBER
3	0A1029050	OTHER	CA	BLUE SHIELD PROVIDER NUMBER

General Provider Information

NPI Number	:	1184643629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH STEVENS M.D.

Provider Business Mailing Address
First Line	:	3268 WATERSTONE AVE
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89044-1867
Country	:	US
Telephone Number	:	815-378-8514
Fax Number	:	805-540-3344

Provider Business Practice Location Address
First Line	:	3268 WATERSTONE AVE
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89044-1867
Country	:	US
Telephone Number	:	815-378-8514
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	05/05/2025

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