Basic Information
| Provider Information | |||||||||
| NPI: | 1700881240 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEPHENS | ||||||||
| FirstName: | GORDON | ||||||||
| MiddleName: | MARCUS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 704 EDWARDS AVE | ||||||||
| Address2: | |||||||||
| City: | WESTCLIFFE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812528835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197832380 | ||||||||
| FaxNumber: | 7192832377 | ||||||||
| Practice Location | |||||||||
| Address1: | 704 EDWARDS AVE | ||||||||
| Address2: | |||||||||
| City: | WESTCLIFFE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812528835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197832380 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 08/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0521077 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100217800C | 05 | KS | MEDICAID |