Provider Demographics
NPI:1962703009
Name:CHUCK STEVENSON OD PA
Entity type:Organization
Organization Name:CHUCK STEVENSON OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:G
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
Authorized Official - Phone:850-892-5514
Mailing Address - Street 1:PO BOX 1289
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32435-1289
Mailing Address - Country:US
Mailing Address - Phone:850-892-5514
Mailing Address - Fax:850-892-0189
Practice Address - Street 1:770 US HIGHWAY 331 S
Practice Address - Street 2:SUITE 1
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435-3300
Practice Address - Country:US
Practice Address - Phone:850-892-5514
Practice Address - Fax:850-892-0189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP0002311152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084170600Medicaid
U01013Medicare UPIN