Healthcare Provider Details

I. General information

NPI: 1174570964
Provider Name (Legal Business Name): SUTTER GOULD MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 05/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 S FAIRMONT AVE #130/135
LODI CA
95240-5100
US

IV. Provider business mailing address

600 COFFEE RD
MODESTO CA
95355-4201
US

V. Phone/Fax

Practice location:
  • Phone: 209-366-2001
  • Fax:
Mailing address:
  • Phone: 209-524-1211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN A MITNICK
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 209-521-6097