Provider Demographics
NPI:1770694101
Name:ETHEREDGE, STEPHEN NORFLEET (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:NORFLEET
Last Name:ETHEREDGE
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 1:365 HAWTHORNE AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3107
Mailing Address - Country:US
Mailing Address - Phone:510-832-6131
Mailing Address - Fax:
Practice Address - Street 1:365 HAWTHORNE AVE
Practice Address - Street 2:STE 103
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3107
Practice Address - Country:US
Practice Address - Phone:510-832-6131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC386472086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C386470Medicaid
CA00C386471Medicare PIN
CA00C386470Medicaid
CA760000205Medicare PIN
CA00C386472Medicare PIN
CA00C386470Medicare PIN
CA230000724Medicare PIN