Provider Demographics
NPI:1831196849
Name:WAGSTAFF, STEPHEN JOHN (DPM)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JOHN
Last Name:WAGSTAFF
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 SOUTH ELISEO DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904
Mailing Address - Country:US
Mailing Address - Phone:415-925-1150
Mailing Address - Fax:415-925-1154
Practice Address - Street 1:1321 SOUTH ELISEO DRIVE
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904
Practice Address - Country:US
Practice Address - Phone:415-925-1150
Practice Address - Fax:415-925-1154
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4439213ES0000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU96589Medicare UPIN
CA000E44390Medicare PIN