Provider Demographics
NPI:1073947305
Name:ADVANCED SLEEP AND GASTROENTEROLOGY LABORATORIES, INC
Entity Type:Organization
Organization Name:ADVANCED SLEEP AND GASTROENTEROLOGY LABORATORIES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:SAM
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-751-7165
Mailing Address - Street 1:PO BOX 3068
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-9032
Mailing Address - Country:US
Mailing Address - Phone:209-751-7165
Mailing Address - Fax:209-579-2354
Practice Address - Street 1:4206 TECHNOLOGY DR
Practice Address - Street 2:SUITE 2
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-8769
Practice Address - Country:US
Practice Address - Phone:209-492-0735
Practice Address - Fax:209-579-2354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66389207RG0100X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty