Provider Demographics
NPI:1053334813
Name:STEPHENS, DWIGHT GREGORY (DPM)
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:GREGORY
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 N PRAIRIE AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4505
Mailing Address - Country:US
Mailing Address - Phone:310-671-5800
Mailing Address - Fax:310-671-5810
Practice Address - Street 1:323 N PRAIRIE AVE
Practice Address - Street 2:SUITE 320
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4502
Practice Address - Country:US
Practice Address - Phone:310-671-5800
Practice Address - Fax:310-671-5810
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2206213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB277243OtherMEDICARE
CAZZZ86328ZMedicaid
CACB277243OtherMEDICARE NHIC
CA753069253OtherBLUE CROSS
CAZZZ39493ZOtherBLUE SHIELD OF CALIFORNIA
CAW16357Medicare ID - Type UnspecifiedNHIC MEDICARE
CAZZZ39493ZOtherBLUE SHIELD OF CALIFORNIA