Healthcare Provider Details

I. General information

NPI: 1982762761
Provider Name (Legal Business Name): STEPHEN JOHN GROTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 10/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 DIAMOND ST
LAGUNA BEACH CA
92651-3404
US

IV. Provider business mailing address

554 DIAMOND ST
LAGUNA BEACH CA
92651-3404
US

V. Phone/Fax

Practice location:
  • Phone: 949-306-7383
  • Fax: 949-497-1141
Mailing address:
  • Phone: 949-306-7383
  • Fax: 949-497-1141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG36991
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberG36991
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: