Provider Demographics
NPI:1326471509
Name:IDAHOSA, STEPHEN AZETA (BA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:AZETA
Last Name:IDAHOSA
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:934 ROSE ST APT 301
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19601-1465
Mailing Address - Country:US
Mailing Address - Phone:646-734-9312
Mailing Address - Fax:
Practice Address - Street 1:934 ROSE ST APT 301
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19601-1465
Practice Address - Country:US
Practice Address - Phone:646-734-9312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-12
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies