Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | E2206 | CA |
Y | 222Z00000X | Podiatrist | E2206 | CA |
NPI | 1053334813 |
---|---|
Provider Name | Dr. Dwight Gregory Stephens |
First Address | Beverly Hills, CA 90212-0816 |
Second Address | Inglewood, CA 90301-4502 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
753069253 | BLUE CROSS (01) | CA |
T11228 | (02) | CA |
ZZZ39493Z | BLUE SHIELD OF CALIFORNIA (01) | CA |
ZZZ86328Z | (05) | CA |