Provider Demographics
NPI:1902860539
Name:PROVER, STEPHEN ERWIN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ERWIN
Last Name:PROVER
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 1:23326 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE #375
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-3725
Mailing Address - Country:US
Mailing Address - Phone:310-373-0527
Mailing Address - Fax:310-373-6915
Practice Address - Street 1:23326 HAWTHORNE BLVD
Practice Address - Street 2:SUITE #375
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3725
Practice Address - Country:US
Practice Address - Phone:310-373-0527
Practice Address - Fax:310-373-6915
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA034057174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW9172OtherMEDICARE PTAN
CAW9172OtherMEDICARE PTAN
CAA27347Medicare UPIN