Provider Demographics
NPI:1689628687
Name:ABEDON, STEPHEN ISRAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ISRAEL
Last Name:ABEDON
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 6102
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-6102
Mailing Address - Country:US
Mailing Address - Phone:415-884-3418
Mailing Address - Fax:415-883-3406
Practice Address - Street 1:1900 SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2200
Practice Address - Country:US
Practice Address - Phone:650-691-6503
Practice Address - Fax:650-991-6755
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG703122085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G703120Medicaid
110247226OtherRAILROAD MEDICARE
CA00G703120Medicaid
CA00G703120Medicare PIN
CA00G703128Medicare PIN
CA00G703121Medicare PIN
CAE38357Medicare UPIN
CA00G703129Medicare PIN
110247226OtherRAILROAD MEDICARE
CA00G7031211Medicare PIN
CA00G7031210Medicare PIN
CA00G703125Medicare PIN
CA00G703122Medicare PIN
CA00G703124Medicare PIN
CA00G703126Medicare PIN