MEDICARE: DR. MARIETTA ABELLERA SUMAQUIAL M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	A38362	CA

General Provider Information

NPI Number	:	1053480780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARIETTA ABELLERA SUMAQUIAL M.D.

Provider Business Mailing Address
First Line	:	PO BOX 779
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95201-0779
Country	:	US
Telephone Number	:	209-373-2800
Fax Number	:	209-373-2873

Provider Business Practice Location Address
First Line	:	2401 W TURNER RD
Second Line	:	SUITE 450
City	:	LODI
State	:	CA
Zip	:	95242-2182
Country	:	US
Telephone Number	:	209-370-1700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	02/03/2012

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