Active NPI
Stephen Norfleet Etheredge, MD
- Vascular Surgery Physician
- Oakland, CA
National Provider Identifier
1770694101
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Vascular Surgery Physician
- License
- C38647
- Practice address
- 365 Hawthorne Ave
Ste 103
Oakland, CA 94609-3107 - Phone
- (510) 832-6131
- NPI assigned
- Aug 31, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Vascular Surgery Physician | 2086S0129X | C38647 | CA | Primary |
Addresses
Primary practice location
365 Hawthorne Ave
Ste 103
Oakland, CA 94609-3107
Mailing address
365 Hawthorne Ave
Ste 103
Oakland, CA 94609-3107
Phone (510) 832-6131
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 00C386470 | Medicaid | CA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| C38647 | CA | MD | Vascular Surgery Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156982400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1211328000000",
"number": "1770694101",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "365 HAWTHORNE AVE",
"address_2": "STE 103",
"city": "OAKLAND",
"state": "CA",
"postal_code": "946093107",
"telephone_number": "510-832-6131"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "365 HAWTHORNE AVE",
"address_2": "STE 103",
"city": "OAKLAND",
"state": "CA",
"postal_code": "946093107",
"telephone_number": "510-832-6131"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ETHEREDGE",
"first_name": "STEPHEN",
"middle_name": "NORFLEET",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-08-31",
"last_updated": "2008-05-21",
"status": "A"
},
"taxonomies": [
{
"code": "2086S0129X",
"taxonomy_group": "",
"desc": "Surgery, Vascular Surgery",
"state": "CA",
"license": "C38647",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "00C386470",
"state": "CA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Oakland, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 21, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.