=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306009501
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK CHARLES STAHL MD PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2008
-----------------------------------------------------
Last Update Date | 08/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5022 PENDLETON ST
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92109-1549
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-247-6653
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 858
-----------------------------------------------------
City | HERSHEY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17033-0858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-243-1455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | A112688
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | MD452856
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------