Provider Demographics
NPI:1427033786
Name:STEVENS, MARK L (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:STEVENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2923
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77902-2923
Mailing Address - Country:US
Mailing Address - Phone:361-576-4164
Mailing Address - Fax:361-576-5684
Practice Address - Street 1:501 E COLORADO ST
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-6025
Practice Address - Country:US
Practice Address - Phone:361-579-8300
Practice Address - Fax:361-579-8303
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ0283207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00L06COtherBCBS OF TX #
74-2678144OtherTAX ID #
TX111531302Medicaid
TX111531302Medicaid
74-2678144OtherTAX ID #