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General NPI Number Information
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NPI Number | 1174868897
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Entity Type | Organization
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Legal Business Name | MARCH LANE PEDIATRIC GROUP
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Dates
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Enumeration Date | 12/06/2012
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Last Update Date | 12/06/2012
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Provider Practice Location Address
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Address Line | 73 W MARCH LN STE F
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City | STOCKTON
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State | CA
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Zip | 95207-5726
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Country | US
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Telephone | 209-952-5555
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Fax | 209-952-1907
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Provider Business Mailing Address
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Address Line | 73 W MARCH LN STE F
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City | STOCKTON
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State | CA
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Zip | 95207-5726
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Country | US
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Telephone | 209-952-5555
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Fax | 209-952-1907
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. ANGE MOUTTAPA
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Credential | M.D.
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Telephone | 209-952-5555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | A25317
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License Number State | CA
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