Provider Demographics
NPI:1639154438
Name:HART, LYNETTE C (MD)
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:C
Last Name:HART
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 213008
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95213-9008
Mailing Address - Country:US
Mailing Address - Phone:209-467-6330
Mailing Address - Fax:
Practice Address - Street 1:1800 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6019
Practice Address - Country:US
Practice Address - Phone:209-467-6330
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G284190174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G284190Medicaid
CA00G284190Medicaid
CAA43723Medicare UPIN