MEDICARE: CHARLES E STOOPACK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	G45525	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G45525	OTHER	CA	STATE MEDICAL LICENSE

General Provider Information

NPI Number	:	1770573255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES E STOOPACK M.D.

Provider Business Mailing Address
First Line	:	2067 W VISTA WAY
Second Line	:
City	:	VISTA
State	:	CA
Zip	:	92083-6001
Country	:	US
Telephone Number	:	760-758-3000
Fax Number	:	760-758-5943

Provider Business Practice Location Address
First Line	:	2067 W VISTA WAY
Second Line	:
City	:	VISTA
State	:	CA
Zip	:	92083-6031
Country	:	US
Telephone Number	:	760-758-3000
Fax Number	:	760-758-5943

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2005
Last Update Date	:	07/08/2007

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Directions to “ CHARLES E STOOPACK M.D.” Practice Location

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