Healthcare Provider Details

I. General information

NPI: 1699719708
Provider Name (Legal Business Name): SCOTT GEORGE BOURNS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 COTTAGE AVE
MANTECA CA
95336-4935
US

IV. Provider business mailing address

7210 MURRAY DR
STOCKTON CA
95210-3339
US

V. Phone/Fax

Practice location:
  • Phone: 209-624-5800
  • Fax:
Mailing address:
  • Phone: 209-373-2832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A 9042
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: