Healthcare Provider Details

I. General information

NPI: 1427110691
Provider Name (Legal Business Name): J. LAWRENCE DEPOLO M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 E MARCH LN SUITE C300
STOCKTON CA
95210-6629
US

IV. Provider business mailing address

1801 E MARCH LN SUITE C300
STOCKTON CA
95210-6629
US

V. Phone/Fax

Practice location:
  • Phone: 209-948-1425
  • Fax: 209-464-0193
Mailing address:
  • Phone: 209-948-1425
  • Fax: 209-464-0193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA22978
License Number StateCA

VIII. Authorized Official

Name: DR. J LAWRENCE DEPOLO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 209-948-1425