Provider Demographics
NPI:1467642215
Name:STIPHO, SALLY (MD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:
Last Name:STIPHO
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 1:4060 FOURTH AVE
Mailing Address - Street 2:STE 240
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2120
Mailing Address - Country:US
Mailing Address - Phone:619-291-6064
Mailing Address - Fax:619-291-3492
Practice Address - Street 1:4060 FOURTH AVE
Practice Address - Street 2:STE 240
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2120
Practice Address - Country:US
Practice Address - Phone:619-291-6064
Practice Address - Fax:619-291-3492
Is Sole Proprietor?:No
Enumeration Date:2007-07-27
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33890207RG0100X
CAA104647207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A5085ZMedicare PIN