Provider Demographics
NPI:1174502223
Name:SUMMERS, STEPHEN THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:THOMAS
Last Name:SUMMERS
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 1:786 3RD AVE.
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910
Mailing Address - Country:US
Mailing Address - Phone:619-425-0797
Mailing Address - Fax:
Practice Address - Street 1:786 3RD AVE
Practice Address - Street 2:#B
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-5826
Practice Address - Country:US
Practice Address - Phone:619-425-0797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70943208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G70943Medicaid
CAGR0062500OtherMEDICAID GROUP NUMBER
CAGR0062500OtherMEDICAID GROUP NUMBER
CAW13244Medicare PIN
CAW13244Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER