=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548427487
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEPHEN RANDOLPH GRIFFITH M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2008
-----------------------------------------------------
Last Update Date | 05/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21633 AVENUE 24
-----------------------------------------------------
City | CHOWCHILLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93610-9650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-665-6100
-----------------------------------------------------
Fax | 559-665-6125
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5098 N VAN NESS BLVD
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93711-2850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-431-7465
-----------------------------------------------------
Fax | 559-431-1090
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | C34670
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------