Provider Demographics
NPI:1356352108
Name:PINE, STEPHEN (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:PINE
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 1:950 S GRAND AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90015-3999
Mailing Address - Country:US
Mailing Address - Phone:323-669-4346
Mailing Address - Fax:323-635-1891
Practice Address - Street 1:4618 FOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1977
Practice Address - Country:US
Practice Address - Phone:323-669-4346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC33483207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA35294Medicare UPIN
CAC33483Medicare ID - Type Unspecified