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General NPI Number Information
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NPI Number | 1558564872
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Entity Type | Individual
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Provider Name | STEPHEN KENTON WATERBROOK M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/06/2007
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Last Update Date | 11/15/2022
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Provider Practice Location Address
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Address Line | 150 CATHERINE LN SUITE J
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City | GRASS VALLEY
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State | CA
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Zip | 95945-5719
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Country | US
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Telephone | 530-272-2257
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Fax | 530-272-6977
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Provider Business Mailing Address
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Address Line | 150 CATHERINE LN STE J
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City | GRASS VALLEY
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State | CA
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Zip | 95945-5719
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Country | US
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Telephone | 530-269-8191
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Fax | 530-205-9023
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | A94355
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License Number State | CA
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