Basic Information
Provider Information
NPI: 1154352771
EntityType: 2
ReplacementNPI:  
OrganizationName: SUTTER GOULD MEDICAL FOUNDATION
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
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Credential:  
OtherOrganizationName: STOCKTON MEDICAL PLAZA PRIMARY CARE
OtherOrganizationType: 3
OtherLastName:  
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Mailing Information
Address1: 600 COFFEE RD
Address2:  
City: MODESTO
State: CA
PostalCode: 953554201
CountryCode: US
TelephoneNumber: 2095241211
FaxNumber:  
Practice Location
Address1: 2505 W HAMMER LN
Address2:  
City: STOCKTON
State: CA
PostalCode: 952092839
CountryCode: US
TelephoneNumber: 2099577050
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/05/2006
LastUpdateDate: 10/03/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: MITNICK
AuthorizedOfficialFirstName: STEVEN
AuthorizedOfficialMiddleName: A
AuthorizedOfficialTitleorPosition: MEDICAL DIRECTOR
AuthorizedOfficialTelephone: 2095216097
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000XG25105CAN193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal Medicine 
207RE0101XG41310CAN193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
208000000XA16204CAN193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPediatrics 
207Q00000XG32207CAY193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansFamily Medicine 

No ID Information.


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