Provider Demographics
NPI:1326462250
Name:PATRICIO LAUDER A PROFESSIONAL MEDICAL CORP.
Entity Type:Organization
Organization Name:PATRICIO LAUDER A PROFESSIONAL MEDICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIO
Authorized Official - Middle Name:
Authorized Official - Last Name:LAUDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-339-9022
Mailing Address - Street 1:PO BOX 55243
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-8743
Mailing Address - Country:US
Mailing Address - Phone:209-339-9022
Mailing Address - Fax:209-339-9033
Practice Address - Street 1:1006 NUT TREE RD
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-4100
Practice Address - Country:US
Practice Address - Phone:209-339-9022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64160207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A641600Medicare PIN