MEDICARE: CENTRAL STOCKTON MEDICAL CLINIC

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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ25352Z	OTHER	CA	GROUP PTAN

General Provider Information

NPI Number	:	1932148343
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL STOCKTON MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	1144 NORMAN DR
Second Line	:	SUITE 102
City	:	MANTECA
State	:	CA
Zip	:	95336-5925
Country	:	US
Telephone Number	:	209-823-1152
Fax Number	:	209-823-3376

Provider Business Practice Location Address
First Line	:	1508 WEST LN
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95205-3340
Country	:	US
Telephone Number	:	209-948-2886
Fax Number	:	209-948-2831

Authorized Official
Title or Position	:	DIRECTOR/OWNER
Name	:	DR. PHILIP A EDINGTON
Credential	:	MD
Telephone Number	:	209-948-5515

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	01/04/2008

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Directions to “CENTRAL STOCKTON MEDICAL CLINIC ” Practice Location

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