Provider Demographics
NPI:1871511667
Name:MANFREDI, STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:
Last Name:MANFREDI
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:FILE 57351
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-7351
Mailing Address - Country:US
Mailing Address - Phone:800-818-5438
Mailing Address - Fax:
Practice Address - Street 1:1117 E DEVONSHIRE AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-3083
Practice Address - Country:US
Practice Address - Phone:909-652-2811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31935207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G31935OtherBLUE CROSS
00G319350OtherBLUE SHIELD
CA00G319350Medicaid
G31935OtherRIVERSIDE CO
CA00G319351Medicare PIN
930018144Medicare PIN
CT0243Medicare PIN
00G319350OtherBLUE SHIELD
00G319350Medicare PIN
G31935OtherRIVERSIDE CO
ZZZ30469ZMedicare PIN