Healthcare Provider Details

I. General information

NPI: 1164420782
Provider Name (Legal Business Name): RICHARD DUANE STAHL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 GENESEE AVE STE 560
LA JOLLA CA
92037-1229
US

IV. Provider business mailing address

9850 GENESEE AVE STE 560
LA JOLLA CA
92037-1229
US

V. Phone/Fax

Practice location:
  • Phone: 858-455-6330
  • Fax: 858-455-5408
Mailing address:
  • Phone: 858-455-6330
  • Fax: 858-455-5408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberG60745
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: