Provider Demographics
NPI:1104878040
Name:STEVENS, GERALD (MD)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:
Last Name:STEVENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT LA 21650
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1650
Mailing Address - Country:US
Mailing Address - Phone:949-263-8620
Mailing Address - Fax:949-263-1639
Practice Address - Street 1:31872 SOUTH COAST HIGHWAY
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651
Practice Address - Country:US
Practice Address - Phone:949-499-7195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA425652085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A426570OtherBLUE SHIELD
CA00A426570OtherBLUE SHIELD
A29618Medicare UPIN
CAWA42657AMedicare PIN
CAWA42657BMedicare PIN