MEDICARE: SUTTER GOULD MEDICAL FOUNDATION

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	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891741963
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUTTER GOULD MEDICAL FOUNDATION

Provider Business Mailing Address
First Line	:	600 COFFEE RD
Second Line	:
City	:	MODESTO
State	:	CA
Zip	:	95355-4201
Country	:	US
Telephone Number	:	209-524-1211
Fax Number	:

Provider Business Practice Location Address
First Line	:	3132 W MARCH LN
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95219-2354
Country	:	US
Telephone Number	:	209-954-3370
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	STEVEN A MITNICK
Credential	:	MD
Telephone Number	:	209-521-6097

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	08/22/2020

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