Healthcare Provider Details

I. General information

NPI: 1538157953
Provider Name (Legal Business Name): BENEDICTO M. ESTOESTA M.D. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 02/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 S HIGHWAY 26 STE 1
VALLEY SPRINGS CA
95252-8422
US

IV. Provider business mailing address

55 S HIGHWAY 26 STE 1 P O BOX 1570
VALLEY SPRINGS CA
95252-8422
US

V. Phone/Fax

Practice location:
  • Phone: 209-772-8906
  • Fax: 209-772-8950
Mailing address:
  • Phone: 209-772-8906
  • Fax: 209-772-8950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA49318
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberA49318
License Number StateCA

VIII. Authorized Official

Name: DR. BENEDICTO MERCADO ESTOESTA
Title or Position: PRESIDENT
Credential: MD
Phone: 209-772-8906