Healthcare Provider Details

I. General information

NPI: 1356459986
Provider Name (Legal Business Name): STEPHEN J. WHITGOB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 12/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 TELEGRAPH AVE
BERKELEY CA
94705-2018
US

IV. Provider business mailing address

PO BOX 640
BELLEVILLE NJ
07109-0640
US

V. Phone/Fax

Practice location:
  • Phone: 510-644-2900
  • Fax: 510-644-8241
Mailing address:
  • Phone: 973-751-7515
  • Fax: 973-751-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG24893
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: