Provider Demographics
NPI:1669575866
Name:STOUDER, MICHAEL DALE (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DALE
Last Name:STOUDER
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 1:26795 PORTOLA PKWY
Mailing Address - Street 2:
Mailing Address - City:FOOTHILL RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92610-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26795 PORTOLA PKWY
Practice Address - Street 2:
Practice Address - City:FOOTHILL RANCH
Practice Address - State:CA
Practice Address - Zip Code:92610
Practice Address - Country:US
Practice Address - Phone:949-829-9403
Practice Address - Fax:949-829-9422
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56697207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG56697EMedicare PIN
CAWG56697FMedicare PIN
CAE27235Medicare UPIN