Provider Demographics
NPI:1003032038
Name:DAVID M.STEVENSON
Entity Type:Organization
Organization Name:DAVID M.STEVENSON
Other - Org Name:DAVID M. STEVENSON APRN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE PROPRIATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:203-288-6800
Mailing Address - Street 1:215 SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-2125
Mailing Address - Country:US
Mailing Address - Phone:203-288-6800
Mailing Address - Fax:203-287-1953
Practice Address - Street 1:215 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-2125
Practice Address - Country:US
Practice Address - Phone:203-288-6800
Practice Address - Fax:203-287-1953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002031261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004192267Medicaid
CT004192267Medicaid
CT500000488Medicare ID - Type UnspecifiedMEDICARE