Provider Demographics
NPI:1538161229
Name:STEPHENS, ALAN L (MD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:L
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7920 W JEFFERSON BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4166
Mailing Address - Country:US
Mailing Address - Phone:260-490-7111
Mailing Address - Fax:260-490-2286
Practice Address - Street 1:7901 S 12TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49024
Practice Address - Country:US
Practice Address - Phone:269-372-3000
Practice Address - Fax:269-372-3500
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301113439208200000X
IN01044904A208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104366787Medicaid
IN200090260Medicaid
OH2068202Medicaid
MI104366787Medicaid
IN200090260Medicaid
IN186080GMedicare PIN