Healthcare Provider Details

I. General information

NPI: 1063803203
Provider Name (Legal Business Name): SACRAMENTO PEDIATRICS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7501 HOSPITAL DR SUITE 206
SACRAMENTO CA
95823-5405
US

IV. Provider business mailing address

7237 E SOUTHGATE DR SUITE A
SACRAMENTO CA
95823-2637
US

V. Phone/Fax

Practice location:
  • Phone: 916-682-7481
  • Fax: 916-422-6500
Mailing address:
  • Phone: 916-422-6635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA34512
License Number StateCA

VIII. Authorized Official

Name: DR. STEPHANIE ANNE WALTON
Title or Position: PRESIDENT
Credential: MD
Phone: 916-422-6635