Basic Information
Provider Information | |||||||||
NPI: | 1205820966 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEVENSON | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3555 KNICKERBOCKER RD | ||||||||
Address2: |   | ||||||||
City: | SAN ANGELO | ||||||||
State: | TX | ||||||||
PostalCode: | 769047610 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3259499555 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 210 E HARRIS AVE | ||||||||
Address2: |   | ||||||||
City: | SAN ANGELO | ||||||||
State: | TX | ||||||||
PostalCode: | 769035906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3256581511 | ||||||||
FaxNumber: | 3254812166 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/08/2005 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | L3842 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 152047001 | 05 | TX |   | MEDICAID | 8845M1 | 01 | TX | BCBS | OTHER |