Provider Demographics
NPI:1225096498
Name:AMADOR SURGERY CENTER
Entity Type:Organization
Organization Name:AMADOR SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:DUTRA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:209-223-5938
Mailing Address - Street 1:223 CLINTON ROAD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-2680
Mailing Address - Country:US
Mailing Address - Phone:209-223-5938
Mailing Address - Fax:209-257-1599
Practice Address - Street 1:223 CLINTON ROAD
Practice Address - Street 2:SUITE 204
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2680
Practice Address - Country:US
Practice Address - Phone:209-223-5938
Practice Address - Fax:209-257-1599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5539103OtherCCN
CA2116688OtherFIRST HEALTH
CAAS1640OtherBLUE CROSS
CA141370XXOtherPREFERRED CARE
CASUR01640FMedicaid
CA141370XXOtherPREFERRED CARE
CASUR01640FMedicaid