Provider Demographics
NPI:1861433880
Name:STEVENS, MARK E (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
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 1747
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84059-1747
Mailing Address - Country:US
Mailing Address - Phone:800-789-7342
Mailing Address - Fax:616-975-9827
Practice Address - Street 1:750 W 800 N
Practice Address - Street 2:ER DEPARTMENT
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057
Practice Address - Country:US
Practice Address - Phone:801-714-6570
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT51308081205207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD4584Medicaid
UTD4584Medicaid