Healthcare Provider Details

I. General information

NPI: 1942488267
Provider Name (Legal Business Name): STEPHANIE KELTER FOGELSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2008
Last Update Date: 10/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 CORPORATE DR SUITE #240
LADERA RANCH CA
92694-2106
US

IV. Provider business mailing address

600 CORPORATE DR SUITE #240
LADERA RANCH CA
92694-2106
US

V. Phone/Fax

Practice location:
  • Phone: 949-364-8411
  • Fax: 949-364-8511
Mailing address:
  • Phone: 949-364-8411
  • Fax: 949-364-8511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA92164
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: