Provider Demographics
NPI:1003999756
Name:STEVENSON, CHARLES GORDON III (OD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:GORDON
Last Name:STEVENSON
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Mailing Address - Country:US
Mailing Address - Phone:850-892-5514
Mailing Address - Fax:850-892-0189
Practice Address - Street 1:770 HWY 331 SOUTH
Practice Address - Street 2:SUITE 1
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435
Practice Address - Country:US
Practice Address - Phone:850-892-5514
Practice Address - Fax:850-892-0189
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP0002311152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL084170600Medicaid
FL084170600Medicaid
FLU01013Medicare UPIN
FL19762Medicare PIN