Provider Demographics
NPI: | 1942236963 |
---|---|
Name: | STEVENER, RONALD C (OD) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | RONALD |
Middle Name: | C |
Last Name: | STEVENER |
Suffix: | |
Gender: | M |
Credentials: | OD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 3323 S LOOP 256 |
Mailing Address - Street 2: | |
Mailing Address - City: | PALESTINE |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75801-6977 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 903-729-6361 |
Mailing Address - Fax: | 903-723-1186 |
Practice Address - Street 1: | 3323 S LOOP 256 |
Practice Address - Street 2: | |
Practice Address - City: | PALESTINE |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75801-6977 |
Practice Address - Country: | US |
Practice Address - Phone: | 903-729-6361 |
Practice Address - Fax: | 903-723-1186 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-23 |
Last Update Date: | 2008-10-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 2762TG | 152W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 410039275 | Other | RR MCARE |
TX | 1304970001 | Other | DMERC |
TX | 11365 | Other | SUPERIOR HEALTH (CHIPS) |
TX | 112465301 | Medicaid | |
TX | 82220N | Other | BCBS |
TX | 82220N | Medicare ID - Type Unspecified | |
TX | 112465301 | Medicaid |