Provider Demographics
NPI:1437113065
Name:MANTECA MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:MANTECA MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/COO
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CROASDALE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-823-7646
Mailing Address - Street 1:1262 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4962
Mailing Address - Country:US
Mailing Address - Phone:209-823-7646
Mailing Address - Fax:209-824-5374
Practice Address - Street 1:1262 E NORTH ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4962
Practice Address - Country:US
Practice Address - Phone:209-823-7646
Practice Address - Fax:209-824-5374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24460207Q00000X
CAA54203207R00000X
CAC43012207R00000X
CA20A7379207V00000X
CAG55402207V00000X
CAA51139208000000X
CAA50060208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG96348Medicare UPIN
CAG21440Medicare UPIN
CAA521440Medicare UPIN
CAF34134Medicare UPIN
CAF33372Medicare UPIN
CAF39733Medicare UPIN
CAA23990Medicare UPIN