Provider Demographics
NPI:1053341552
Name:STEVENS, ROBERT WAYNE
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:WAYNE
Last Name:STEVENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:368 W PIKE ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3240
Mailing Address - Country:US
Mailing Address - Phone:770-963-1918
Mailing Address - Fax:678-817-0330
Practice Address - Street 1:368 W PIKE ST
Practice Address - Street 2:SUITE 202
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3240
Practice Address - Country:US
Practice Address - Phone:770-963-1918
Practice Address - Fax:678-817-0330
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO06793111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52820948002OtherBC/BS PROVIDER I.D.
GA35ZCGJWMedicare ID - Type Unspecified
GAU85478Medicare UPIN