Provider Demographics
NPI:1154318764
Name:SOUNG, JERRY (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:SOUNG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 N EL DORADO ST
Mailing Address - Street 2:SUITE 17
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5930
Mailing Address - Country:US
Mailing Address - Phone:209-465-5107
Mailing Address - Fax:209-465-7653
Practice Address - Street 1:1610 N EL DORADO ST
Practice Address - Street 2:SUITE 17
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5930
Practice Address - Country:US
Practice Address - Phone:209-465-5107
Practice Address - Fax:209-465-7653
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73550207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A735500Medicaid
CA00A735500Medicaid
I13672Medicare UPIN