Provider Demographics
NPI:1376638965
Name:STEVENSON ORTHOPAEDIC MEDICAL CLINIC
Entity Type:Organization
Organization Name:STEVENSON ORTHOPAEDIC MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:V
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-674-1211
Mailing Address - Street 1:575 E HARDY ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4040
Mailing Address - Country:US
Mailing Address - Phone:310-674-1211
Mailing Address - Fax:310-674-8668
Practice Address - Street 1:575 E HARDY ST
Practice Address - Street 2:SUITE 105
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4040
Practice Address - Country:US
Practice Address - Phone:310-674-1211
Practice Address - Fax:310-674-8668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48296207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G482960Medicaid
CA5348800001Medicare NSC
CAA92805Medicare UPIN
CA00G482960Medicaid