MEDICARE: DR. WALTER E STEVENS JR. M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	G58132	CA

General Provider Information

NPI Number	:	1720058134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WALTER E STEVENS JR. M.D.

Provider Business Mailing Address
First Line	:	1330 SAN BERNARDINO RD
Second Line	:	SUITE J
City	:	UPLAND
State	:	CA
Zip	:	91786-4928
Country	:	US
Telephone Number	:	909-981-5406
Fax Number	:	909-981-4933

Provider Business Practice Location Address
First Line	:	1330 SAN BERNARDINO RD
Second Line	:	SUITE J
City	:	UPLAND
State	:	CA
Zip	:	91786-4928
Country	:	US
Telephone Number	:	909-981-5406
Fax Number	:	909-981-4933

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2006
Last Update Date	:	06/09/2012

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