MEDICARE: STOCKTON NEPHROLOGY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician	A111373	CA

General Provider Information

NPI Number	:	1790110880
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STOCKTON NEPHROLOGY, INC.

Provider Business Mailing Address
First Line	:	1525 N EL DORADO ST
Second Line	:	SUITE 1
City	:	STOCKTON
State	:	CA
Zip	:	95204-5932
Country	:	US
Telephone Number	:	209-465-5107
Fax Number	:	209-465-7653

Provider Business Practice Location Address
First Line	:	1525 N EL DORADO ST
Second Line	:	SUITE 1
City	:	STOCKTON
State	:	CA
Zip	:	95204-5932
Country	:	US
Telephone Number	:	209-465-5107
Fax Number	:	209-465-7653

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LAN NGOC QUANG
Credential	:	M.D.
Telephone Number	:	415-283-5772

Provider Enumeration Date	:	09/07/2013
Last Update Date	:	02/03/2017

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