Provider Demographics
NPI:1114254711
Name:STEVENS, JEFFREY LYLE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LYLE
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 1:100 E CALIFORNIA BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3205
Mailing Address - Country:US
Mailing Address - Phone:626-568-8838
Mailing Address - Fax:626-583-8838
Practice Address - Street 1:100 E CALIFORNIA BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3205
Practice Address - Country:US
Practice Address - Phone:626-568-8838
Practice Address - Fax:626-583-8838
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC148445207W00000X
SD7997207W00000X
ORMD151338207W00000X
WAMD 60151762207W00000X
PAMD438137207W00000X
IDM-15046207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1760541569OtherGROUP NPI
CAW20602Medicare UPIN
CABW463AMedicare UPIN