Provider Demographics
NPI:1386657666
Name:STOCKTON ENDOSCOPY CENTER LLC
Entity Type:Organization
Organization Name:STOCKTON ENDOSCOPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:N
Authorized Official - Last Name:MARCUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:650-496-4141
Mailing Address - Street 1:PO BOX 39000
Mailing Address - Street 2:DEPT 33691 09
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94139
Mailing Address - Country:US
Mailing Address - Phone:650-493-7729
Mailing Address - Fax:650-493-7959
Practice Address - Street 1:415 E HARDING WAY
Practice Address - Street 2:SUITE E
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204
Practice Address - Country:US
Practice Address - Phone:209-942-1179
Practice Address - Fax:209-942-2200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30000792261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ31751ZMedicare ID - Type Unspecified