Healthcare Provider Details

I. General information

NPI: 1154372951
Provider Name (Legal Business Name): INDRA DE MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 07/10/2022
Certification Date: 07/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 N CALIFORNIA ST
STOCKTON CA
95204-6019
US

IV. Provider business mailing address

3905 GLEN ABBY CIR
STOCKTON CA
95219-1800
US

V. Phone/Fax

Practice location:
  • Phone: 209-943-2000
  • Fax:
Mailing address:
  • Phone: 209-462-9100
  • Fax: 209-462-9101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberC52396
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: