Provider Demographics
NPI:1699959460
Name:STEVENS, MICHAEL HENRY (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:HENRY
Last Name:STEVENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N 1900 E
Mailing Address - Street 2:3C120
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0006
Mailing Address - Country:US
Mailing Address - Phone:801-581-8915
Mailing Address - Fax:801-585-5744
Practice Address - Street 1:30 N 1900 E
Practice Address - Street 2:3C120
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0006
Practice Address - Country:US
Practice Address - Phone:801-581-8915
Practice Address - Fax:801-585-5744
Is Sole Proprietor?:No
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT149395174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist