Provider Demographics
NPI:1942342928
Name:ELTGROTH, STEFAN ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:STEFAN
Middle Name:ANTHONY
Last Name:ELTGROTH
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 1:2480 LLEWELLYN AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GEORGE G MEADE
Mailing Address - State:MD
Mailing Address - Zip Code:20755-5800
Mailing Address - Country:US
Mailing Address - Phone:410-278-1813
Mailing Address - Fax:
Practice Address - Street 1:2105 OAKINGTON ROAD KIRK US ARMY HEALTH CLINIC
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MD
Practice Address - Zip Code:21005
Practice Address - Country:US
Practice Address - Phone:410-278-1813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDOO53622207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDVAD000Medicare UPIN