Healthcare Provider Details

I. General information

NPI: 1548317167
Provider Name (Legal Business Name): VIRENDER JIT KAMBOJ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 09/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2522 GRAND CANAL BLVD
STOCKTON CA
95207-8213
US

IV. Provider business mailing address

4728 LONGCOVE DR
STOCKTON CA
95219-1749
US

V. Phone/Fax

Practice location:
  • Phone: 209-952-1434
  • Fax: 209-952-5059
Mailing address:
  • Phone: 209-477-7046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA36755
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberA36755
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberA36755
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA36755
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: