Basic Information
| Provider Information | |||||||||
| NPI: | 1225096498 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMADOR SURGERY CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 223 CLINTON ROAD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | JACKSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956422680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092235938 | ||||||||
| FaxNumber: | 2092571599 | ||||||||
| Practice Location | |||||||||
| Address1: | 223 CLINTON ROAD | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | JACKSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956422680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092235938 | ||||||||
| FaxNumber: | 2092571599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUTRA | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2092235938 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 5539103 | 01 | CA | CCN | OTHER | 2116688 | 01 | CA | FIRST HEALTH | OTHER | AS1640 | 01 | CA | BLUE CROSS | OTHER | 141370XX | 01 | CA | PREFERRED CARE | OTHER | SUR01640F | 05 | CA | MEDICAID |