Provider Demographics
NPI:1083894638
Name:STAHL, JERUSHA E (MD)
Entity Type:Individual
Prefix:
First Name:JERUSHA
Middle Name:E
Last Name:STAHL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3362 SOUTHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-6243
Mailing Address - Country:US
Mailing Address - Phone:917-232-1821
Mailing Address - Fax:
Practice Address - Street 1:69 GROVE ST
Practice Address - Street 2:
Practice Address - City:NEW CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06840-5325
Practice Address - Country:US
Practice Address - Phone:844-359-8363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR214779207R00000X
WA61425057207R00000X
CAA101309207R00000X
CT1992372403261QM2500X
NJ1992372403261QM2500X
NY1043889967261QM2500X
CT76444207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty