Healthcare Provider Details

I. General information

NPI: 1427472745
Provider Name (Legal Business Name): GASTRO CONSULTANTS OF SACRAMENTO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 N MARKET BLVD SUITE 45
SACRAMENTO CA
95834-1986
US

IV. Provider business mailing address

262 BURGENLAND AVE
TURLOCK CA
95382-0343
US

V. Phone/Fax

Practice location:
  • Phone: 209-751-7165
  • Fax:
Mailing address:
  • Phone: 209-751-7165
  • Fax: 209-579-2354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberG66389
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberG66389
License Number StateCA

VIII. Authorized Official

Name: DR. JONATHAN SAM DAVIDSON
Title or Position: CEO
Credential: M.D.
Phone: 209-751-7165