Provider Demographics
NPI:1588690721
Name:STEVENS, RICHARD L (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
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 1:416 E 4TH AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015-3672
Mailing Address - Country:US
Mailing Address - Phone:229-273-8501
Mailing Address - Fax:229-273-2515
Practice Address - Street 1:416 E 4TH AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3672
Practice Address - Country:US
Practice Address - Phone:229-273-8501
Practice Address - Fax:229-273-2515
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056227207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA394168697AMedicaid
GA394168697AMedicaid
GA11SCFJMMedicare ID - Type Unspecified