Provider Demographics
NPI:1194801738
Name:STEVENS, DONALD EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:EDWARD
Last Name:STEVENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:945 HILDEBRAND LN NE
Practice Address - Street 2:SUITE 100
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-2877
Practice Address - Country:US
Practice Address - Phone:206-991-2121
Practice Address - Fax:206-991-2151
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019980207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P0 0016565OtherRAILROAD MEDICARE
WA1118389Medicaid
WAMD00019980OtherMEDICAL LICENSE
P0 0016565OtherRAILROAD MEDICARE
71 -- 0940330OtherFEDERAL TAX ID
WAA07023Medicare UPIN