Healthcare Provider Details

I. General information

NPI: 1649496597
Provider Name (Legal Business Name): GENY B. BURGOS M. D. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 E MARCH LN STE C340
STOCKTON CA
95210-6629
US

IV. Provider business mailing address

1801 E MARCH LN STE C340
STOCKTON CA
95210-6629
US

V. Phone/Fax

Practice location:
  • Phone: 209-939-9512
  • Fax: 209-939-1226
Mailing address:
  • Phone: 209-939-9512
  • Fax: 209-939-1226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number00A536100
License Number StateCA

VIII. Authorized Official

Name: DR. GENY BRABANTE BURGOS
Title or Position: M. D.
Credential: M.D.
Phone: 209-939-9512