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General NPI Number Information
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NPI Number | 1023169471
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Entity Type | Organization
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Legal Business Name | DELTA PODIATRY GROUP, INC.
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Dates
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Enumeration Date | 01/14/2007
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Last Update Date | 04/02/2009
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Provider Practice Location Address
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Address Line | 1205 N HUNTER ST
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City | STOCKTON
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State | CA
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Zip | 95202-1409
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Country | US
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Telephone | 209-464-7367
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Fax | 209-464-1801
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Provider Business Mailing Address
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Address Line | 1205 N HUNTER ST
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City | STOCKTON
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State | CA
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Zip | 95202-1409
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Country | US
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Telephone | 209-464-7367
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Fax | 209-464-1801
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Authorized Official
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Title or Position | PRESIDENT
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Name | LYNN ROBERT JOHNSON
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Credential | DPM
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Telephone | 209-464-7367
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | E1406
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License Number State | CA
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