Provider Demographics
NPI:1790992279
Name:STENEHJEM, JEROME (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:
Last Name:STENEHJEM
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 1:8765 AERO DR STE 310
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1767
Mailing Address - Country:US
Mailing Address - Phone:858-541-4480
Mailing Address - Fax:858-541-4452
Practice Address - Street 1:8765 AERO DR STE 310
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1767
Practice Address - Country:US
Practice Address - Phone:858-541-4480
Practice Address - Fax:858-541-4452
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55883174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4401818Medicaid
CAA93405Medicare UPIN