Provider Demographics
NPI:1336246446
Name:STEVENS, CARL WAYNE II (MD)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:WAYNE
Last Name:STEVENS
Suffix:II
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 1:203 S 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-4324
Mailing Address - Country:US
Mailing Address - Phone:601-649-9706
Mailing Address - Fax:601-649-9708
Practice Address - Street 1:203 S 12TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4324
Practice Address - Country:US
Practice Address - Phone:601-649-9706
Practice Address - Fax:601-649-9708
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15762207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119265Medicaid
MS040000167Medicare Oscar/Certification
F96595Medicare UPIN