Basic Information
Provider Information
NPI: 1003001363
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: STEVENS
FirstName: CHARLES
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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: 02/06/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207LP2900XA104563CAY Allopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
207LP2900X036.118504ILN Allopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine

ID Information
IDTypeStateIssuerDescription
709633805CA MEDICAID


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