Provider Demographics
NPI:1467849216
Name:MOCK, STEPHANIE A
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:MOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1734 EWER DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-3701
Mailing Address - Country:US
Mailing Address - Phone:408-623-4265
Mailing Address - Fax:
Practice Address - Street 1:2120 S STATE COLLEGE BLVD APT 2093
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-6240
Practice Address - Country:US
Practice Address - Phone:408-623-4265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE132318146N00000X
CA20000232612083S0010X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Multi-Specialty