Healthcare Provider Details

I. General information

NPI: 1003639808
Provider Name (Legal Business Name): STEFAN PENTSCHEV MD MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2024
Last Update Date: 11/01/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30926 E KINGS CANYON RD
SQUAW VALLEY CA
93675-9601
US

IV. Provider business mailing address

30926 E KINGS CANYON RD
SQUAW VALLEY CA
93675-9601
US

V. Phone/Fax

Practice location:
  • Phone: 559-332-1112
  • Fax: 559-332-1112
Mailing address:
  • Phone: 559-332-1112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. STEFAN I PENTSCHEV,
Title or Position: OWNER & PHYSICIAN
Credential: MD
Phone: 559-332-1112