Provider Demographics
NPI:1417971839
Name:MILLBERN, STEPHEN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:MILLBERN
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 1:5463 FREMONTIA LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-1007
Mailing Address - Country:US
Mailing Address - Phone:619-265-7810
Mailing Address - Fax:619-265-8929
Practice Address - Street 1:5463 FREMONTIA LN
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-1007
Practice Address - Country:US
Practice Address - Phone:619-265-7810
Practice Address - Fax:619-265-8929
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC36162207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C361620OtherBLUE SHIELD OF CA
CA00C361620Medicaid
CAWC36162AMedicare PIN
CA00C361620OtherBLUE SHIELD OF CA