Basic Information
| Provider Information | |||||||||
| NPI: | 1003001363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STEVENS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | RAYMOND | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1665 S IMPERIAL AVE STE D | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922434247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604820212 | ||||||||
| FaxNumber: | 7604820166 | ||||||||
| Practice Location | |||||||||
| Address1: | 1665 S IMPERIAL AVE STE D | ||||||||
| Address2: | |||||||||
| City: | EL CENTRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922434247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604820212 | ||||||||
| FaxNumber: | 7604820166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2007 | ||||||||
| LastUpdateDate: | 05/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 05/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | A104563 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7096338 | 05 | CA | MEDICAID |