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General NPI Number Information
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NPI Number | 1316190796
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Entity Type | Organization
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Legal Business Name | SUTTER GOULD MEDICAL FOUNDATION
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Dates
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Enumeration Date | 10/29/2008
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Last Update Date | 03/06/2020
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Provider Practice Location Address
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Address Line | 8011 DON AVE
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City | STOCKTON
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State | CA
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Zip | 95209
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Country | US
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Telephone | 209-955-3047
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Fax |
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Provider Business Mailing Address
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Address Line | 8011 DON AVE
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City | STOCKTON
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State | CA
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Zip | 95209
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Country | US
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Telephone | 209-955-3047
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Fax | 209-473-9382
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. STEVEN A MITNICK
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Credential | MD
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Telephone | 209-521-6097
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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