Healthcare Provider Details

I. General information

NPI: 1699899708
Provider Name (Legal Business Name): ROBERT JOHN STADELHOFER CAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5494 PONY EXPRESS TRAIL
POLLOCK PINES CA
95726
US

IV. Provider business mailing address

PO BOX 1721
PLACERVILLE CA
95667-1721
US

V. Phone/Fax

Practice location:
  • Phone: 530-644-3758
  • Fax:
Mailing address:
  • Phone: 530-306-4097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number03-056467
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: