Provider Demographics
NPI:1043323629
Name:CROUGHAN, STEPHEN JOHN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JOHN
Last Name:CROUGHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 927704
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92192-7704
Mailing Address - Country:US
Mailing Address - Phone:310-627-2378
Mailing Address - Fax:619-423-0340
Practice Address - Street 1:2937 BEYER BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154
Practice Address - Country:US
Practice Address - Phone:310-627-2378
Practice Address - Fax:801-749-4963
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41669207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A416690Medicaid
C35531Medicare UPIN
CAWA41669Medicare ID - Type Unspecified