Provider Demographics
NPI:1447201603
Name:MORELAND, STEPHEN I III (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:I
Last Name:MORELAND
Suffix:III
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:DEPT LA 21632
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91185-1632
Mailing Address - Country:US
Mailing Address - Phone:858-564-1400
Mailing Address - Fax:858-564-1500
Practice Address - Street 1:10150 SORRENTO VALLEY RD
Practice Address - Street 2:SUITE 320
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1635
Practice Address - Country:US
Practice Address - Phone:858-454-4235
Practice Address - Fax:858-454-4644
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG550892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G550890Medicaid
CA00G550890OtherBLUE SHIELD PIN
CAWG55089BMedicare PIN
CA00G550890OtherBLUE SHIELD PIN
CA00G550890Medicaid
CAWG55089AMedicare PIN
CAWG55089CMedicare PIN