Provider Demographics
NPI:1720058134
Name:STEVENS, WALTER E JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:E
Last Name:STEVENS
Suffix:JR
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 1:1330 SAN BERNARDINO RD
Mailing Address - Street 2:SUITE J
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4928
Mailing Address - Country:US
Mailing Address - Phone:909-981-5406
Mailing Address - Fax:909-981-4933
Practice Address - Street 1:1330 SAN BERNARDINO RD
Practice Address - Street 2:SUITE J
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4928
Practice Address - Country:US
Practice Address - Phone:909-981-5406
Practice Address - Fax:909-981-4933
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2012-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58132174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG58132Medicare ID - Type Unspecified
CAE89182Medicare UPIN
CA00G581320Medicare PIN
CACW832AMedicare PIN