Provider Demographics
NPI:1700801131
Name:STEPHENS, KENTON EDGAR JR (MD)
Entity type:Individual
Prefix:
First Name:KENTON
Middle Name:EDGAR
Last Name:STEPHENS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 743896
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3896
Mailing Address - Country:US
Mailing Address - Phone:907-375-2000
Mailing Address - Fax:907-375-5558
Practice Address - Street 1:2751 DEBARR RD STE B320
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-6805
Practice Address - Country:US
Practice Address - Phone:907-375-2000
Practice Address - Fax:907-375-5558
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4620208G00000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKG30828Medicare UPIN