Healthcare Provider Details

I. General information

NPI: 1619910346
Provider Name (Legal Business Name): TRAVERS J MCLOUGHLIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 S HAM LN
LODI CA
95242-3512
US

IV. Provider business mailing address

311 S HAM LN
LODI CA
95242-3512
US

V. Phone/Fax

Practice location:
  • Phone: 209-365-1761
  • Fax: 209-333-3673
Mailing address:
  • Phone: 209-368-5262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberA92339
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: