=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780670422
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK A WINCHESTER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2005
-----------------------------------------------------
Last Update Date | 07/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5301 F ST #117
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95819-3226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-733-1788
-----------------------------------------------------
Fax | 916-733-1787
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1010 HURLEY WAY #475
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95825-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-561-6818
-----------------------------------------------------
Fax | 916-561-4263
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | G34163
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------