Basic Information
| Provider Information | |||||||||
| NPI: | 1811918931 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STOCKTON PEDIATRIC MED. GROUP, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STOCKTON PEDIATRICS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2349 N CALIFORNIA ST | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952045505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094692229 | ||||||||
| FaxNumber: | 2094662436 | ||||||||
| Practice Location | |||||||||
| Address1: | 2349 N CALIFORNIA ST | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952045505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094692229 | ||||||||
| FaxNumber: | 2094662436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 04/03/2009 | ||||||||
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| AuthorizedOfficialLastName: | OLIVEIRA | ||||||||
| AuthorizedOfficialFirstName: | JAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2094692229 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 0700081405 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.