Healthcare Provider Details

I. General information

NPI: 1346468840
Provider Name (Legal Business Name): EDWARD C GREENLEAF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2027 GRAND CANAL BLVD STE 25
STOCKTON CA
95207-6650
US

IV. Provider business mailing address

PO BOX 14
STOCKTON CA
95201-0014
US

V. Phone/Fax

Practice location:
  • Phone: 209-475-1111
  • Fax: 209-475-1119
Mailing address:
  • Phone: 209-475-1111
  • Fax: 209-475-1119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License NumberG51488
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberG51488
License Number StateCA

VIII. Authorized Official

Name: DR. EDWARD C GREENLEAF
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 209-481-8312