Provider Demographics
NPI:1356459986
Name:WHITGOB, STEPHEN J (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:J
Last Name:WHITGOB
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:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-0640
Mailing Address - Country:US
Mailing Address - Phone:973-751-7515
Mailing Address - Fax:973-751-1394
Practice Address - Street 1:2900 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2018
Practice Address - Country:US
Practice Address - Phone:510-644-2900
Practice Address - Fax:510-644-8241
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG24893207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA42436Medicare UPIN
CA00G248931Medicare ID - Type Unspecified