Basic Information
| Provider Information | |||||||||
| NPI: | 1841242559 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VUKSINICH | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7096 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952670096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099567725 | ||||||||
| FaxNumber: | 2099567733 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MISSION BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092237500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 08/13/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | C41691 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00C416910 | 05 | CA | MEDICAID |