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General NPI Number Information
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NPI Number | 1689709008
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Entity Type | Individual
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Provider Name | WILLIAM GRANT STEVENS M.D.
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Gender | Male
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Dates
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Enumeration Date | 02/23/2007
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Last Update Date | 10/20/2010
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Provider Practice Location Address
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Address Line | 4644 LINCOLN BLVD STE 552
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City | MARINA DEL REY
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State | CA
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Zip | 90292-6391
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Country | US
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Telephone | 310-827-2653
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Fax | 310-827-1493
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Provider Business Mailing Address
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Address Line | 4644 LINCOLN BLVD STE 552
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City | MARINA DEL REY
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State | CA
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Zip | 90292-6391
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Country | US
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Telephone | 310-827-2653
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Fax | 310-827-1493
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | G45892
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License Number State | CA
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