Healthcare Provider Details

I. General information

NPI: 1780883496
Provider Name (Legal Business Name): JEREMY SCOTT STUPIN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2185 CITRACADO PKWY
ESCONDIDO CA
92029-4159
US

IV. Provider business mailing address

5191 CHELSEA ST
LA JOLLA CA
92037-7909
US

V. Phone/Fax

Practice location:
  • Phone: 442-281-3000
  • Fax:
Mailing address:
  • Phone: 646-483-7950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA100178
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036175588
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: