Healthcare Provider Details

I. General information

NPI: 1154352771
Provider Name (Legal Business Name): SUTTER GOULD MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 W HAMMER LN
STOCKTON CA
95209-2839
US

IV. Provider business mailing address

600 COFFEE RD
MODESTO CA
95355-4201
US

V. Phone/Fax

Practice location:
  • Phone: 209-957-7050
  • Fax:
Mailing address:
  • Phone: 209-524-1211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG25105
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberG41310
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA16204
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG32207
License Number StateCA

VIII. Authorized Official

Name: STEVEN A MITNICK
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 209-521-6097