Healthcare Provider Details

I. General information

NPI: 1770690505
Provider Name (Legal Business Name): ALAN S NAKANISHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1617 SAINT MARKS PLZ SUITE D
STOCKTON CA
95207-6423
US

IV. Provider business mailing address

1617 SAINT MARKS PLZ SUITE D
STOCKTON CA
95207-6423
US

V. Phone/Fax

Practice location:
  • Phone: 209-478-1797
  • Fax: 209-478-1224
Mailing address:
  • Phone: 209-478-1797
  • Fax: 209-478-1224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG012131
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: