Healthcare Provider Details

I. General information

NPI: 1154424299
Provider Name (Legal Business Name): ANTIOCH MEDICAL PARK MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 LONE TREE WAY
ANTIOCH CA
94509-6065
US

IV. Provider business mailing address

3737 LONE TREE WAY
ANTIOCH CA
94509-6065
US

V. Phone/Fax

Practice location:
  • Phone: 925-754-9223
  • Fax: 925-754-3945
Mailing address:
  • Phone: 925-754-9223
  • Fax: 925-754-3945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA19234
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberG44114
License Number StateCA

VIII. Authorized Official

Name: DR. J GENE ZIMMERMAN
Title or Position: SENIOR MD
Credential: MD
Phone: 925-754-9223