Provider Demographics
NPI:1003001363
Name:STEVENS, CHARLES RAYMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RAYMOND
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 1:1665 S IMPERIAL AVE STE D
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-4247
Mailing Address - Country:US
Mailing Address - Phone:760-482-0212
Mailing Address - Fax:760-482-0166
Practice Address - Street 1:1665 S IMPERIAL AVE STE D
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4247
Practice Address - Country:US
Practice Address - Phone:760-482-0212
Practice Address - Fax:760-482-0166
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA104563207LP2900X
IL036.118504207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7096338Medicaid
CAASO41ZMedicare PIN