Basic Information
Provider Information | |||||||||
NPI: | 1184852584 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEVENSON | ||||||||
FirstName: | CRAIG | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD, MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 75-5751 KUAKINI HWY STE 203 | ||||||||
Address2: |   | ||||||||
City: | KAILUA KONA | ||||||||
State: | HI | ||||||||
PostalCode: | 967401753 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8083265629 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 74-5214 KEANALEHU DR | ||||||||
Address2: |   | ||||||||
City: | KAILUA KONA | ||||||||
State: | HI | ||||||||
PostalCode: | 96740 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8083555600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/24/2009 | ||||||||
LastUpdateDate: | 02/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0006X | 11346 | OR | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics | 2080P0006X | 15025 | HI | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 639726 | 05 | HI |   | MEDICAID |