Healthcare Provider Details

I. General information

NPI: 1548418759
Provider Name (Legal Business Name): GAMAL MOHAMED KHALIL MAREY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2008
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 W ACACIA ST STE 1
STOCKTON CA
95203-2400
US

IV. Provider business mailing address

530 W ACACIA ST STE 1
STOCKTON CA
95203-2400
US

V. Phone/Fax

Practice location:
  • Phone: 209-242-7098
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number174119
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number0101269316
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: