Healthcare Provider Details

I. General information

NPI: 1316147986
Provider Name (Legal Business Name): INDRA DE M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 W MARCH LN STE A1
STOCKTON CA
95207-5263
US

IV. Provider business mailing address

3905 GLEN ABBY CIR
STOCKTON CA
95219-1800
US

V. Phone/Fax

Practice location:
  • Phone: 209-462-9100
  • Fax: 209-462-9101
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: DR. INDRA DE
Title or Position: PRESIDENT
Credential: MD
Phone: 209-462-9100