Healthcare Provider Details

I. General information

NPI: 1659010270
Provider Name (Legal Business Name): STEPHEN SENDEROFF
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 CAMPUS POINT DR
LA JOLLA CA
92037-1300
US

IV. Provider business mailing address

1415 ROSS AVE
EL CENTRO CA
92243-4306
US

V. Phone/Fax

Practice location:
  • Phone: 800-926-8273
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA62094
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: