Healthcare Provider Details

I. General information

NPI: 1346727682
Provider Name (Legal Business Name): CASCADE CARDIOVASCULAR SURGERY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1617 N CALIFORNIA ST STE 1D
STOCKTON CA
95204-6117
US

IV. Provider business mailing address

1617 N CALIFORNIA ST STE 1D
STOCKTON CA
95204-6117
US

V. Phone/Fax

Practice location:
  • Phone: 209-948-1234
  • Fax:
Mailing address:
  • Phone: 209-948-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: DONALD STOWELL
Title or Position: OWNER
Credential: MD
Phone: 209-948-1234