Provider Demographics
NPI:1417169665
Name:VALLEY SLEEP DISORDERS CENTER OF SAN ANDREAS MEDICAL GROUP
Entity Type:Organization
Organization Name:VALLEY SLEEP DISORDERS CENTER OF SAN ANDREAS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:MONIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-466-8011
Mailing Address - Street 1:1805 N CALIFORNIA STREET
Mailing Address - Street 2:SUITE 206
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-9037
Mailing Address - Country:US
Mailing Address - Phone:209-466-8011
Mailing Address - Fax:209-466-0250
Practice Address - Street 1:564 MOUNTAIN RANCH ROAD
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249
Practice Address - Country:US
Practice Address - Phone:209-754-5374
Practice Address - Fax:209-754-5376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G311730207RP1001X
CA00A45770207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A45770Medicare ID - Type UnspecifiedDEEPAK SHRIVASTAVA M.D.
CAE25069Medicare UPIN
CA00G311730Medicare ID - Type UnspecifiedROBERT G. MONIE M.D.
CAA44676Medicare UPIN