Provider Demographics
NPI:1982603171
Name:STEVENS, CHARLES SAMUEL (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:SAMUEL
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 1:221 W KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-2965
Mailing Address - Country:US
Mailing Address - Phone:210-736-5043
Mailing Address - Fax:
Practice Address - Street 1:1122 AUSTIN HWY
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-4844
Practice Address - Country:US
Practice Address - Phone:210-342-6488
Practice Address - Fax:210-342-6725
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE8936207ZD0900X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C22266Medicare UPIN