Healthcare Provider Details

I. General information

NPI: 1427180520
Provider Name (Legal Business Name): STOCKTON CARDIO THORACIC SURG MD G
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 02/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 209-948-1234
  • Fax: 209-462-9233
Mailing address:
  • Phone: 209-948-1234
  • Fax: 209-462-9233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberG23097
License Number StateCA

VIII. Authorized Official

Name: MS. JUDEE L WILLHITE
Title or Position: BILLER
Credential:
Phone: 209-948-1236