Provider Demographics
NPI:1952368169
Name:STEVENS, JACK OWEN (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:OWEN
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 1:10420 PEONIA CT
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78733-5709
Mailing Address - Country:US
Mailing Address - Phone:512-698-1772
Mailing Address - Fax:
Practice Address - Street 1:10420 PEONIA CT
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78733-5709
Practice Address - Country:US
Practice Address - Phone:512-698-1772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4728207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG09983Medicare UPIN