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General NPI Number Information
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NPI Number | 1316147986
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Entity Type | Organization
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Legal Business Name | INDRA DE M.D., INC.
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Dates
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Enumeration Date | 07/23/2007
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Last Update Date | 03/11/2019
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Provider Practice Location Address
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Address Line | 2333 W MARCH LN STE A1
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City | STOCKTON
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State | CA
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Zip | 95207-5263
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Country | US
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Telephone | 209-462-9100
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Fax | 209-462-9101
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Provider Business Mailing Address
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Address Line | 3905 GLEN ABBY CIR
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City | STOCKTON
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State | CA
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Zip | 95219-1800
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Country | US
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Telephone | 209-462-9100
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Fax | 209-462-9101
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. INDRA DE
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Credential | MD
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Telephone | 209-462-9100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number | C52396
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License Number State | CA
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