Healthcare Provider Details

I. General information

NPI: 1174882526
Provider Name (Legal Business Name): ERICA ILENA STEVENS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

PO BOX 844658
DALLAS TX
75284-4658
US

V. Phone/Fax

Practice location:
  • Phone: 703-776-3582
  • Fax: 571-665-6492
Mailing address:
  • Phone: 254-724-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0101287395
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberS0384
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberC203894
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number4301102430
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: