Healthcare Provider Details

I. General information

NPI: 1588612154
Provider Name (Legal Business Name): STEPHEN IRA WASSERMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9350 CAMPUS POINT DR SUITE 2A
LA JOLLA CA
92037-1300
US

IV. Provider business mailing address

2361 ALMERIA CT
LA JOLLA CA
92037-7201
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-8322
  • Fax: 858-534-7517
Mailing address:
  • Phone: 858-822-4261
  • Fax: 858-534-7517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberA23431
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: