Provider Demographics
NPI:1114280930
Name:CENTRAL CALIFORNIA NEONATOLOGY GROUP, INC
Entity Type:Organization
Organization Name:CENTRAL CALIFORNIA NEONATOLOGY GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHETAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-353-3000
Mailing Address - Street 1:3116 W MARCH LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2369
Mailing Address - Country:US
Mailing Address - Phone:209-473-6555
Mailing Address - Fax:209-473-6544
Practice Address - Street 1:9300 VALLEY CHILDRENS PL
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636-8761
Practice Address - Country:US
Practice Address - Phone:559-353-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGMedicaid