Provider Demographics
NPI:1013030006
Name:DELTA HEART & MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:DELTA HEART & MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BUNMI
Authorized Official - Middle Name:
Authorized Official - Last Name:OLOWOYEYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-951-9884
Mailing Address - Street 1:1801 E MARCH LN
Mailing Address - Street 2:A-170
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-6629
Mailing Address - Country:US
Mailing Address - Phone:209-951-9884
Mailing Address - Fax:209-951-7873
Practice Address - Street 1:1801 E MARCH LN
Practice Address - Street 2:A-170
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6629
Practice Address - Country:US
Practice Address - Phone:209-951-9884
Practice Address - Fax:209-951-7873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48005207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC3822OtherRAILROAD MEDICARE PIN
OOA480050OtherPTAN
CA00A480050Medicaid
CA037196OtherHILL PHYSICIANS MED GROUP
CA6923038Medicaid
CAZZZ64420ZOtherBLUE SHIELD OF CA
OOA480050OtherPTAN
CA037196OtherHILL PHYSICIANS MED GROUP