Provider Demographics
NPI:1083858492
Name:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA - DEPT OF MODESTO
Entity Type:Organization
Organization Name:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA - DEPT OF MODESTO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEVONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KAJI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-353-5700
Mailing Address - Street 1:9300 VALLEY CHILDRENS PL
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8761
Mailing Address - Country:US
Mailing Address - Phone:559-353-5700
Mailing Address - Fax:559-353-5708
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:570
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4500
Practice Address - Country:US
Practice Address - Phone:209-572-3880
Practice Address - Fax:209-572-3349
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECIALTY MEDICAL GROUP CENTRAL CALIFORNIA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-29
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1013968296OtherSMG GROUP MAIN NPI
CAGR0078680Medicaid
CA1013968296OtherSMG GROUP MAIN NPI