Provider Demographics
NPI:1689709008
Name:STEVENS, WILLIAM GRANT (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:GRANT
Last Name:STEVENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GRANT
Other - Middle Name:
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4644 LINCOLN BLVD STE 552
Mailing Address - Street 2:
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:310-827-1493
Practice Address - Street 1:4644 LINCOLN BLVD STE 552
Practice Address - Street 2:
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:310-827-1493
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45892174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954748839OtherTIN