Healthcare Provider Details

I. General information

NPI: 1306867213
Provider Name (Legal Business Name): CAPITOL UROLOGY MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1561 CREEKSIDE DR SUITE 170
FOLSOM CA
95630
US

IV. Provider business mailing address

1561 CREEKSIDE DR SUITE 170
FOLSOM CA
95630-3492
US

V. Phone/Fax

Practice location:
  • Phone: 916-983-5557
  • Fax: 916-983-7878
Mailing address:
  • Phone: 916-983-5557
  • Fax: 916-983-7878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberG59349
License Number StateCA

VIII. Authorized Official

Name: JOYCE MYERS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 916-983-5557