Basic Information
| Provider Information | |||||||||
| NPI: | 1811222391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAMIEN | ||||||||
| FirstName: | DEEPTHY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 779 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952010779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093732800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 730 N CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | TRACY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953764104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098204500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2009 | ||||||||
| LastUpdateDate: | 02/22/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A109507 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.