Healthcare Provider Details

I. General information

NPI: 1083825491
Provider Name (Legal Business Name): GARY L STEVENSMDPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 04/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 E CENTRAL AVE
WINTER HAVEN FL
33880-3051
US

IV. Provider business mailing address

475 E CENTRAL AVE
WINTER HAVEN FL
33880-3051
US

V. Phone/Fax

Practice location:
  • Phone: 863-293-2147
  • Fax: 863-294-2767
Mailing address:
  • Phone: 863-293-2147
  • Fax: 863-294-2767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberME75661
License Number StateFL

VIII. Authorized Official

Name: DR. GARY L STEVENS
Title or Position: PRESIDENT
Credential: MD
Phone: 863-293-2147