Provider Demographics
NPI:1639444714
Name:GRANT STEVENS, M.D., INC
Entity Type:Organization
Organization Name:GRANT STEVENS, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PALOMARES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-827-2653
Mailing Address - Street 1:4644 LINCOLN BLVD
Mailing Address - Street 2:SUITE 552
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6391
Mailing Address - Country:US
Mailing Address - Phone:310-827-2653
Mailing Address - Fax:310-823-1984
Practice Address - Street 1:4644 LINCOLN BLVD
Practice Address - Street 2:SUITE 552
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6391
Practice Address - Country:US
Practice Address - Phone:310-827-2653
Practice Address - Fax:310-823-1984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-21
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA116508208200000X
CAA94136208200000X
CAG45892208200000X
208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty