Provider Demographics
NPI:1285666743
Name:STOCKTON ORTHOPEDIC MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:STOCKTON ORTHOPEDIC MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:VALDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-948-1641
Mailing Address - Street 1:1901 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-6005
Mailing Address - Country:US
Mailing Address - Phone:209-948-1641
Mailing Address - Fax:209-948-0660
Practice Address - Street 1:1901 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6005
Practice Address - Country:US
Practice Address - Phone:209-948-1641
Practice Address - Fax:209-948-0660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0219850005OtherCIGNA MEDICARE PIN
CA0219850005OtherCIGNA MEDICARE PIN
CAZZZ47892ZMedicare PIN