Basic Information
| Provider Information | |||||||||
| NPI: | 1205891215 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEPHENS | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N BEAVER ST | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860013118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282136235 | ||||||||
| FaxNumber: | 9282136292 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 S WILLARD ST | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863264126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286396025 | ||||||||
| FaxNumber: | 9286345604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 09/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D0079328 | MD | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 01057710A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 40270 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 54351 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00309839 | 01 | IN | RAILROAD MEDICARE | OTHER | 200454180 | 05 | IN | MEDICAID | 7100005620 | 05 | KY | MEDICAID |