Healthcare Provider Details

I. General information

NPI: 1821534686
Provider Name (Legal Business Name): VALLEY PERINATAL & GENETICS DIAGNOSTIC CENTER MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2017
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1617 N CALIFORNIA ST STE. 2D
STOCKTON CA
95204-6117
US

IV. Provider business mailing address

PO BOX 967
LODI CA
95241-0967
US

V. Phone/Fax

Practice location:
  • Phone: 209-933-9888
  • Fax: 209-933-9988
Mailing address:
  • Phone: 209-334-1800
  • Fax: 209-334-2416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberG460810
License Number StateCA

VIII. Authorized Official

Name: JASBIR SINGH GILL
Title or Position: PRESIDENT
Credential: MD
Phone: 209-334-6583