Provider Demographics
NPI:1790787141
Name:STELLA, JONATHAN R (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:R
Last Name:STELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 849697
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-9697
Mailing Address - Country:US
Mailing Address - Phone:805-648-5191
Mailing Address - Fax:805-648-3458
Practice Address - Street 1:100 CASA ST
Practice Address - Street 2:SUITE C
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1883
Practice Address - Country:US
Practice Address - Phone:805-541-1932
Practice Address - Fax:805-541-1653
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA439432085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A439430Medicaid
CA00A439430Medicaid