Provider Demographics
NPI:1245268242
Name:STEVENS, RENE (OD)
Entity type:Individual
Prefix:DR
First Name:RENE
Middle Name:
Last Name:STEVENS
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 1:12737 GLENOAKS BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-4724
Mailing Address - Country:US
Mailing Address - Phone:818-367-1015
Mailing Address - Fax:818-367-3593
Practice Address - Street 1:12737 GLENOAKS BLVD STE 3
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-4724
Practice Address - Country:US
Practice Address - Phone:818-367-1015
Practice Address - Fax:818-367-3593
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11218T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD112180Medicaid
CAOP4873OtherGROUP PTAN
CAOP4873OtherGROUP PTAN
CAU81652Medicare UPIN