Provider Demographics
NPI:1053404947
Name:STEVENS, JOHN C (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:STEVENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 1026
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1026
Mailing Address - Country:US
Mailing Address - Phone:317-274-1201
Mailing Address - Fax:317-278-9905
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:ROC 4270
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-274-7208
Practice Address - Fax:317-274-3442
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-11-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN010302722080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1801852Medicaid
350593390-042OtherTRICARE-DEAC-350593390
000000354898OtherANTHEM-DEAC-350593390
350593390OtherUPA-237328642
MI1053404947Medicaid
IN100227810Medicaid
KY64880370Medicaid
MI1053404947Medicaid
IN100227810Medicaid
KY64880370Medicaid