Provider Demographics
NPI:1548308836
Name:IERARDI, STEPHEN JOHN (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JOHN
Last Name:IERARDI
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 1:24422 AVENIDA DE LA CARLOTA STE 272
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3648
Mailing Address - Country:US
Mailing Address - Phone:949-282-6500
Mailing Address - Fax:949-282-6500
Practice Address - Street 1:24422 AVENIDA DE LA CARLOTA STE 272
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3648
Practice Address - Country:US
Practice Address - Phone:949-282-6500
Practice Address - Fax:949-282-6501
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63246204C00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE04679Medicare UPIN
CAWG63246AMedicare PIN