Provider Demographics
NPI:1164573671
Name:MAMAUAG, JODALIN SIMANGAN
Entity Type:Individual
Prefix:
First Name:JODALIN
Middle Name:SIMANGAN
Last Name:MAMAUAG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 NORTHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-2129
Mailing Address - Country:US
Mailing Address - Phone:916-359-2174
Mailing Address - Fax:
Practice Address - Street 1:2501 NORTHVIEW DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95833-2129
Practice Address - Country:US
Practice Address - Phone:916-359-2174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMTN01174FMedicare ID - Type UnspecifiedMEDICAL