Basic Information
| Provider Information | |||||||||
| NPI: | 1881745313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VESCERA | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7156 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952670156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094676866 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10200 TRINITY PKWY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952197249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093233480 | ||||||||
| FaxNumber: | 2094729102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 05/08/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | G27029 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00G270290 | 05 | CA | MEDICAID |