Provider Demographics
NPI:1972594596
Name:STEVENS, JOHN ALBERT (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ALBERT
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47842-0344
Mailing Address - Country:US
Mailing Address - Phone:765-828-1003
Mailing Address - Fax:765-828-1030
Practice Address - Street 1:777 S MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CLINTON
Practice Address - State:IN
Practice Address - Zip Code:47842-2493
Practice Address - Country:US
Practice Address - Phone:765-828-1003
Practice Address - Fax:765-828-1030
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01043105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200038350Medicaid
IN080141873OtherRR MEDICARE
IN941090V6Medicare PIN
IN252060B1Medicare PIN
IN130910NNMedicare PIN
G12546Medicare UPIN
INM400037700Medicare PIN
IN841350Medicare PIN
IN854700JJJJMedicare PIN
IN080141873OtherRR MEDICARE