=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255520714
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FORT MYERS CENTRE FOR FACIAL PLASTIC AND LASER SURGERY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2007
-----------------------------------------------------
Last Update Date | 09/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15721 NEW HAMPSHIRE CT
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33908-4176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-481-4911
-----------------------------------------------------
Fax | 239-481-6360
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15721 NEW HAMPSHIRE CT
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33908-4176
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-481-4911
-----------------------------------------------------
Fax | 239-481-6360
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | DR. DOUGLAS M STEVENS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 239-481-4911
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | ME0068103
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------