Healthcare Provider Details

I. General information

NPI: 1235443292
Provider Name (Legal Business Name): STEPHEN J. WHITGOB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2010
Last Update Date: 08/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 TELEGRAPH AVE
BERKELEY CA
94705-2018
US

IV. Provider business mailing address

2900 TELEGRAPH AVE
BERKELEY CA
94705-2018
US

V. Phone/Fax

Practice location:
  • Phone: 510-883-9883
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG024893
License Number StateCA

VIII. Authorized Official

Name: STEPHEN J. WHITGOB
Title or Position: PHYSICIAN
Credential:
Phone: 415-883-9883