Provider Demographics
NPI:1659719698
Name:STEVENS, THOMAS M (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:M
Last Name:STEVENS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HOSPITAL PLZ
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WV
Mailing Address - Zip Code:26354-1283
Mailing Address - Country:US
Mailing Address - Phone:304-265-7406
Mailing Address - Fax:304-265-6443
Practice Address - Street 1:1 HOSPITAL PLZ
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354-1283
Practice Address - Country:US
Practice Address - Phone:304-265-7406
Practice Address - Fax:304-265-6443
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2983208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810029816Medicaid
WVWV5945AMedicare PIN