Provider Demographics
NPI:1962614560
Name:STEVENS, GEORGE THOMAS IV (IDC (NAVY))
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:THOMAS
Last Name:STEVENS
Suffix:IV
Gender:M
Credentials:IDC (NAVY)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 TARAWA RD BLDG 327
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92155-5078
Mailing Address - Country:US
Mailing Address - Phone:619-437-5139
Mailing Address - Fax:619-437-5099
Practice Address - Street 1:3330 TARAWA RD BLDG 327
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5078
Practice Address - Country:US
Practice Address - Phone:619-437-5139
Practice Address - Fax:619-437-5099
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman