Provider Demographics
NPI:1881646107
Name:STEVENS, EUGENE A (MD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:A
Last Name:STEVENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 CENTERPOINTE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-8660
Mailing Address - Country:US
Mailing Address - Phone:503-797-2273
Mailing Address - Fax:503-234-8155
Practice Address - Street 1:6445 N GREELEY AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214
Practice Address - Country:US
Practice Address - Phone:503-285-6607
Practice Address - Fax:503-285-3195
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2013-02-14
Deactivation Date:2012-12-28
Deactivation Code:
Reactivation Date:2013-02-14
Provider Licenses
StateLicense IDTaxonomies
ORMD08364207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080158951OtherRR MEDICARE
OR184762Medicaid
080158951OtherRR MEDICARE
ORC91334Medicare UPIN