Healthcare Provider Details

I. General information

NPI: 1669540118
Provider Name (Legal Business Name): STEVENS KIM MD AND STEPHEN LIN MD MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 03/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 W YOKUTS AVE SUITE 3
STOCKTON CA
95207-5713
US

IV. Provider business mailing address

36 W YOKUTS AVE SUITE 3
STOCKTON CA
95207-5713
US

V. Phone/Fax

Practice location:
  • Phone: 209-952-1189
  • Fax: 209-952-1174
Mailing address:
  • Phone: 209-952-1189
  • Fax: 209-952-1174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License NumberG76813
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEVENS YOUNG JUN KIM
Title or Position: SECRETARY AND TREASURER
Credential: M.D.
Phone: 209-952-1189