Provider Demographics
NPI:1649327735
Name:STEVENS, PERRY R (MD)
Entity type:Individual
Prefix:
First Name:PERRY
Middle Name:R
Last Name:STEVENS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1000 NORTHERN BLVD
Mailing Address - Street 2:SUITE 175
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5312
Mailing Address - Country:US
Mailing Address - Phone:516-439-5223
Mailing Address - Fax:516-439-5227
Practice Address - Street 1:1000 NORTHERN BLVD
Practice Address - Street 2:SUITE 175
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5312
Practice Address - Country:US
Practice Address - Phone:516-439-5223
Practice Address - Fax:516-439-5227
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2010-07-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY179574207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01640151Medicaid
NYF95549Medicare UPIN
NY97J151Medicare ID - Type Unspecified